Category Archives: Counseling and Psychotherapy Theory and Practice

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

A Sneak Peek at the Suicide Assessment and Treatment Planning Workshop Coming to Billings on November 8

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Anybody wondering what’s new in suicide assessment and treatment?

If so, come listen to any or all of a very nice suicide prevention/intervention line-up on November 7 and 8 on the campus of Montana State University in Billings. Here’s a news link with detailed info: https://billingsgazette.com/news/local/let-s-talk-montana-suicide-prevention-workshops-coming-to-msub/article_9a6f04ff-376f-56b8-a6a8-9a0160ba1cbb.html

For my part, I’m presenting the latest iteration of the suicide assessment and treatment model Rita and I have been working on for the past couple years. To help make suicide assessment and treatment planning easier, we’ve started using six common sense life domains to organize, understand, and apply specific assessment and intervention tools.

Another unique component of our model is an emphasis on client strengths and wellness. Obviously, in the context of suicide, it’s impossible (and wrong) to ignore clients’ emotional pain and suffering. However, we also think it’s possible (and right) to intermittently recognize, nurture, and focus on clients’ strengths, well-being, and goals.

What follows is a sneak peek at what I’ll be covering on Friday, November 8.

Suicide Interventions and Treatment Planning: Foundational Principles

Two essential principles that cut across all modern evidence-based protocols and evidence-based interventions form the foundation of all contemporary suicide assessment and treatment models:

  • Collaboration – Working in partnership with clients
  • Compassion – Emotional attunement without judgment

Collaborative practitioners work with clients, not on clients. Clients experiencing suicidal thoughts and impulses typically know their struggles from the inside out. Their self-knowledge makes them an invaluable resource. Carl Rogers (1961) put it this way,

It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried. It began to occur to me that unless I had a need to demonstrate my own cleverness and learning, I would do better to rely upon the client for the direction of movement in the process. (p. 11)

Compassionate practitioners resonate with client emotions and engage in respectful and gentle emotional exploration. Although compassion involves an empathic emotional response, it also includes tuning into and respecting client cognitions, beliefs, and experiences. For example, some clients who are suicidal feel spiritually or culturally bereft or disconnected. Regardless of their own beliefs and cultural values, compassionate counselors show empathy for their clients’ particular spiritual or cultural distress.

Clients who are or who become suicidal are often observant, sensitive, and intelligent. If they feel you’re judging them, they’re likely to experience a relationship rupture (Safran, Muran, & Eubanks-Carter, 2011). When ruptures occur, clients typically become less open, less engaged, and less honest about their suicidal thoughts and impulses. They also may become angry, aggressive, and critical of your efforts to be of help. In both cases, relational ruptures signal a need to work on mending the therapeutic relationship.

[For a helpful meta-analysis with recommendations on repairing ruptures, check out this article from the Safran lab: http://www.safranlab.net/uploads/7/6/4/6/7646935/repairing_alliance_ruptures._psychotherapy_2011.pdf%5D

The Six Life Domains

Working with clients who are suicidal can be overwhelming. To help organize and streamline the assessment and treatment planning process, it’s helpful to consider six distinct, but overlapping life domains. These domains provide a holistic description of human functioning. When clients experience suicidal thoughts and impulses, you can be sure the suicidal state will manifest through one or more of these six domains (i.e., emotions, cognitions, interpersonal, physical, spiritual/cultural, and behavioral; see below for a brief description of the six domains). All case examples and content in the workshop use these six domains to focus and organize client problems, goals/strengths, and interventions.

Suicidality as Manifest through Six Life Domains             

The Emotional Domain. A driving force in the suicidal state is excruciating emotional distress. Shneidman called this “psychache” and toward the end of his career concluded: “Suicide is caused by psychache” (1993, p. 53). Extreme distress is experienced subjectively. This is one reason there are so many different suicide risk factors. When a specific experience triggers excruciating distress for a given individual (e.g., unemployment, insomnia, etc.), it may increase suicide risk. Reducing emotional distress and facilitating positive emotional experiences is usually goal #1 in your treatment plan. Treatment plans often target general distress as well as specific and problematic emotions like (a) sadness, (b) shame, (c) fear/anxiety, and (d) guilt/regret.
The Cognitive Domain. Suicidal distress interferes with cognitive functioning. The resulting constricted thinking impairs problem-solving and creativity. The emotional distress and depressed mood associated with suicidality decreases the ability to think of or value alternatives to suicide. Several other cognitive variables are also linked to suicidality, including hopelessness and self-hatred. Most treatment plans will include collaborative problem-solving, and gentle challenging of maladaptive thoughts. Specific interventions may be employed to support client problem-solving, increase client hopefulness, and decrease client self-hatred.
The Interpersonal Domain. Hundreds of studies link social problems to suicidality, suicide attempts, and suicide deaths. Joiner (2005) identified two interpersonal problems that are deeply linked to suicide: thwarted belongingness and perceived burdensomeness. Many risk factors (e.g., recent romantic break-up, family rejection of sexuality, health conditions that cause people to feel like a burden) can exacerbate thwarted belongingness and cause people to perceive themselves as a social burden. Improving interpersonal relationships is often a key part of treatment planning.
The Physical/Biogenetic Domain. Physiological factors can contribute to suicide risk. In particular, researchers have recently focused on agitation or physiological arousal; these physical states tend to push individuals toward suicidal action. Additionally, chronic illness or pain, insomnia, and other disturbing health situations (including addictions) contribute to suicide, especially when accompanied by hopelessness. When present, physical conditions and biogenetic predispositions should be integrated into suicide prevention, treatment planning, and risk management.
The Spiritual/Cultural Domain. Meaningful life experiences can be a protective influence against suicide. No doubt, a wide range of cultural or religious pressures, spiritual/religious exile, or other factors can decrease an individual’s sense of meaning and can contribute to suicidal thoughts and behaviors. Including spiritual or meaning-focused components in a treatment plan can improve outcomes, especially among clients who hold deep spiritual and cultural values.
The Behavioral Domain. All of the preceding life domains can contribute to suicide, but suicide doesn’t occur unless individuals act on suicidal thoughts and impulses. The behavioral domain focuses on suicide intentions and active suicide planning. When clients actively plan or rehearse suicide, they may be doing so to overcome natural fears and aversions to physical pain and death; natural fears and aversions stop many people from suicide. Joiner (2005) and Klonsky and May (2015) have written about how desensitization to physical pain and to ideas of death move people toward suicidal action. Several factors increase risk in this domain and may be relevant to treatment planning, (a) availability of lethal means (especially firearms), (b) using substances for emotional/physical numbing, and (c) repeated suicide rehearsal (e.g., increased cutting behaviors).

*Note: These domains will always overlap, but they can prove helpful as you collaboratively identify problem areas and goals with your client.

If you’re interested in learning more about this suicide assessment and treatment planning model, I hope to see you in Billings on November 8!

 

 

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Writing

The Dialectics of Diagnosis at MFPE in Belgrade

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Today I’m in Bozeman on my way to present to the Montana School Counselors in Belgrade, MT. As my friends at the Big Sky Youth Empowerment Program like to say, “I’m stoked!” I’m stoked because there’s hardly anything much better than spending a day with Montana School Counselors. Woohoo!

My topic tomorrow is “Strategies for Supporting Students with Common Mental Health Conditions.” That means I’ll be reviewing some DSM/ICD diagnostic criteria and that brings me to reflect on the following. . . .

Not long ago (July, 2019), Allsopp, Read, Corcoran, & Kinderman published an article in Psychiatry Research, not so boldly titled, “Heterogeneity in psychiatric diagnostic classification.” Hmm, sounds fascinating (not!).

A few days later, a summary of the article appeared in the less academically and more media oriented, ScienceDaily. The ScienceDaily’s contrasting and much bolder title was, “Psychiatric diagnosis ‘scientifically meaningless.” Wow!

The ScienceDaily summary took the issue even further. They wrote: “A new study, published in Psychiatry Research, has concluded that psychiatric diagnoses are scientifically worthless as tools to identify discrete mental health disorders.”

Did you catch that? Scientifically worthless!

In an interview with ScienceDaily, Allsopp, Read, and Kinderman stoked the passion, and avoided any word-mincing.

Dr. Kate Allsopp said, “Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice. I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.”

Professor Peter Kinderman, University of Liverpool, said: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose. Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria. The diagnostic system wrongly assumes that all distress results from disorder, and relies heavily on subjective judgments about what is normal.”

Professor John Read, University of East London, said: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

In contrast to the authors’ conclusions, nearly every conventional psychiatrist believes the opposite–and emphasizes that psychiatric diagnosis is of great scientific and medical importance. For example, the Midtown Psychiatry and TMS Center website says, “A correct diagnosis helps the psychiatrist formulate the most effective treatment that will result in remission.”

No doubt there.

In addition, although I literally love that Allsopp, Read, and Kinderman are so outspoken about the potential deleterious effects of diagnosis, I think maybe they take it too far. For example, “Shall we pretend that we should provide the same intervention for panic attacks as we provide for conduct disorder, autism spectrum disorder, and gender dysphoria?”

That’s me talking now . . . and as I discussed this with Rita, she amplified that, of course, if you have a student who’s intentionally engaging in violent acts that harm others, we’re not treating them the same as a student who’s suffering panic attacks. Obviously.

Psychiatric diagnosis is a great example of a dialectic. Yes, in some ways it’s meaningless and overblown. And yes, in some ways it provides crucial information that informs our treatment approaches.

This leads me to my final point, and to my handouts.

What’s our School Counseling take-away message?

Let’s keep the baby and throw out with the bathwater.

Let’s de-emphasize labels – because labelling, whether accurate or inaccurate and whether self-inflicted or other inflicted, are possibly pathology-inducing.

Instead, let’s focus on specific behavior patterns, as well as abilities, impairments, stressors, and trauma experiences that interfere with academic achievement, personal and social functioning, and career potential.

In case you’re interested in more on this. My handouts for the workshop are below.

The Powerpoints: MFPE 2019 Belgrade Final

Managing fear and anxiety:Childhood Fears Rev

Student de-escalation tips: De-escalation Handout REV

Why Kids Lie and What to Do About It

 

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Happy Saturday Morning at ACES in Seattle

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Space_Needle_2011-07-04

The Association of Counselor Educators and Supervisors (ACES) conference is underway in Seattle. Seattle is a fabulous location. It’s great to be back in my home state.

It’s also great to be with so many fabulous people. Counselor educators are some of the nicest people on the planet. The conversations are intellectually stimulating, kind, compassionate, and positive relationship skills are on display everywhere.

Speaking of positive relationship skills, this morning, Kim Parrow (a fantastic doc student in our Counseling program at U of Montana) and I are presenting on Evidence-Based Relationship Factors (EBRFs). If you’re not sure what EBRFs are, or want to learn more, then check out the resources below.

The Powerpoints are here: ACES Seattle Kim and John Final REV

A previously published journal article from the Journal of Mental Health Counseling is here: JoMHC EB Article by John SF 2015

Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Trauma, Suicide, and Motivational Interviewing: A Handout for BYEP Mentors

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Sunset

Trauma may be the most common underlying factor contributing to mental disorders. Unfortunately, trauma is often overlooked, partly because it can manifest itself in so many different ways. That said, here are some common definitions. Trauma always involves a stressful trigger that activates a trauma response. Because, like everything, trauma responses are brain-based and involve the body, symptoms affect the whole person.

Old, informal, and useful definitions include:

  • A stressor outside the realm of normal human experience (but sadly, trauma is all-too-common)
  • A betrayal . . . (e.g., something that should not happen)
  • Occurrence of an event that’s emotionally overwhelming

Below I’ve listed the essence of the DSM-5 definition for Post-Traumatic Stress Disorder (note that the whole idea of PTSD centers on the chronic or long-lasting effects of trauma).

Exposure to a traumatic stressor that involves direct personal experience, witnessing, or learning about events involving threatened death, serious injury, or a threat to your physical integrity. The trauma response includes:

  • Intrusion symptoms (recurring unwanted memories, nightmares, flashbacks, and triggered distress)
  • Avoidance of trauma-related thoughts or external cues
  • Negative cognitive alternations (e.g., memory gaps, no joy, etc.)
  • Arousal and reactivity (e.g., irritability, risky behaviors, hypervigilance, insomnia, startle response)

Trauma and trauma responses can be big, medium, and small. Big traumas meet the DSM-5 diagnostic criteria for PTSD or acute stress disorder. Small traumas are usually disturbing and disruptive, but the body and brain adjust to them within 2-3 days. Medium size traumas have lasting effects, but don’t meet formal diagnostic criterial, and are usually referred to as subclinical.

I like to think of Trauma with an uppercase T (like in the DSM) and all other traumas that are difficult, challenging, and require adjustment as traumas with a lowercase t.

What to Say

Sometimes trauma responses or symptoms are visible and obvious. If so, it’s good to say and do some of the following:

  • Listen and show compassion
  • Reassure participants that physical/psychological responses are normal, take up energy & need soothing
  • Note that very effective treatments are available (e.g., This American Life)
  • Brainstorm on what helps
  • Remember: A pill is not a skill
  • Link and universalize (“It’s normal to have pleasant and unpleasant reactions to things we talk about”)
  • Brainstorm on more and less healthy reactions (Using substances is a quick distraction, but not a fix)
  • Share hopeful stories (what skills can be developed?)
  • Self-disclosure can help. But be careful with self-disclosure and remember that it’s not about you

Trauma is a normal and natural human response. You may experience trauma just by listening to people talk about trauma, or you may have your own direct experiences. When in the business of helping others, be sure to take good care of yourself.

Three Suicide Myths

Myth #1: Suicidal thoughts are about death and dying.

Most people assume that suicidal thoughts are about death and dying. On the surface, it seems like a no-brainer: Someone has thoughts about death, therefore, the thoughts must be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Not true. Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.”

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

Believing in this myth can make surviving family members, friends, and helping professionals experience too much guilt and responsibility. In fact, even the most famous suicidologists say that it’s impossible to consistently and accurately predict suicide.

Tips for Talking about Suicide

We need to be able to talk directly about suicide with courage and calmness. But first, we should listen. Here’s what you should listen for in general

  • Emotional pain
  • A sense of feeling trapped or ashamed
  • Not believing that anything can possibly help to reduce the pain and misery

While listening, show acceptance, empathy, and compassion. Remember: suicidal thoughts are not signs of illness or moral failing; if you judge the person, it will make it harder for the person to be open. Also remember: when people talk with you about their suicidal thoughts, that’s a good thing, because you can’t help unless they’re comfortable enough with you to speak openly about their suicidal thoughts and feelings.

Traditional warning signs in particular

Although it’s good to know these warning signs, there’s not much research supporting the idea that anything predicts suicide.

  • Active suicidal thinking that includes planning and talk about wanting to die
  • Preparation and rehearsal behaviors (stockpiling pills, giving away belongings, etc.)
  • Hopelessness related to feeling that the excruciating distress will never end
  • Recklessness, impulsivity, dramatic mood changes
  • Anger, anxiety, and agitation
  • Feeling trapped
  • No reasons for living, no purpose in life, broken relationships
  • Increased alcohol or substance abuse
  • Immense shame or self-hatred

How should I ask about suicide?

The answer to this is always, “Ask directly.” But we can do even better than that. We need to de-shame suicidal thoughts and talk. Before asking, communicate that you know suicidal thoughts are a normal and natural response to emotional pain and disturbing situations. For example, you could ask it this way, “I know that it’s not unusual for people to think about suicide. Have you had any thoughts about suicide?”

What should I say if someone admits to thinking about suicide? You can say things like,

  • Thanks for telling me.
  • It sounds like things have been terribly hard.
  • Thanks for being so honest, that takes courage.
  • I know I can’t instantly make everything better, but I want you to live and I want to help.
  • How can I best support you right now?
  • What can we do together that would help?
  • When you want to give up, tell yourself to hold off for one more day, hour, minute—whatever you can.
  • Or . . . use your good listening skills and reflect back the feelings and thoughts that the person shared.

Resources for Help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

What is Motivational Interviewing?

Motivational interviewing (MI) is an evidence-based approach to treating substance problems, health concerns, and other mental health issues. MI is “person-centered” and based on the foundational principle that clients should be the ones who make the case for change in their lives. MI:

  • Focuses on the common problem of ambivalence about change.
  • Relies on four central listening skills (OARS): open questions, affirming, reflecting, and summarizing.
  • Helps clients transition from less healthy to more healthy behaviors

Four overlapping components combine to create the spirit of MI:

  • Collaboration (partnership; dancing, not wrestling)
  • Acceptance (UPR, accurate empathy, autonomy, affirmation)
  • Compassion (honoring the client’s best interest)
  • Evocation (tapping the client’s well of wisdom)

MI is a specific treatment approach that requires professional training. However, operating on a few basic MI principles can improve nearly anyone’s approach to helping others. For more information, see the book: Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY: Guilford Press.

This handout is from a mentor workshop for the Big Sky Youth Empowerment Program. These ideas are based on research and collected from professionals who have experience working with people who are feeling suicidal. These guidelines should not be considered medical advice and are no substitute for getting an appointment with a licensed health or mental health professional. See: johnsommersflanagan.com for more information.

Counseling and Psychotherapy Theory and Practice

Why Bother Studying Counseling and Psychotherapy Theories?

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A photo of me and my feminist inspiration.

People are often curious about why I would bother writing (and revising) a book on Counseling and Psychotherapy Theories. I usually tell them “I do it for the money” and then laugh like the witch in The Wizard of Oz.

Okay. So it’s obviously not about the money, and I don’t really laugh like that witch, because that would just be frightening and weird and ever since I fell down and hit my head while engaging in a frightening and weird act, I’ve had a pact with myself not to do things that are frightening and weird.

Anyway, to refocus . . . in response to this “Why bother” question, and to elaborate on the post from last week about “What’s your theoretical orientation?” I’m including an excerpt from Chapter One of our Theories textbook. Enjoy.

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About a decade ago, we were flying back from a professional conference when a professor (we’ll call him Darrell) from a large Midwestern university spotted an empty seat next to us. He sat down, and initiated the sort of conversation that probably only happens among university professors.

“I think theories are passé. There has to be a better way to teach students how to actually do counseling and psychotherapy.”

When confronted like this, I (John) like to pretend I’m Carl Rogers (see Chapter 5), so I paraphrased, “You’re thinking there’s a better way.”

“Yes!” he said. “All the textbooks start with Freud and crawl their way to the present. We waste time reviewing outdated theories that were developed by old white men. What’s the point?”

“The old theories seem pointless to you.” I felt congruent with my inner Rogers.

“Worse than pointless.” He glared. “They’re destructive! We live in a diverse culture. I’m a white heterosexual male and they don’t even fit me. We need to teach our students the technical skills to implement empirically supported treatments. That’s what our clients want, and that’s what they deserve. For the next edition of your theories text, you should put traditional theories of counseling and psychotherapy in the dumpster where they belong.”

John’s Carl Rogers persona was about to go all Albert Ellis (see Chapter 8) when the plane’s intercom crackled to life. The flight attendant asked everyone to return to their seats. Our colleague reluctantly rose and bid us farewell.

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On the surface, Darrell’s argument is compelling. Counseling and psychotherapy theories must address unique issues pertaining to women and racial, ethnic, sexual, and religious minorities. Theories also need to be more practical. Students should be able to read a theories chapter and finish with a clear sense of how to apply that theory in practice.

Darrell’s argument is also off target. Although he’s advocating an evidence-based (scientific) orientation, he doesn’t appreciate the central role of theory to science. From early prehistoric writing to the present, theory has been used to guide research and practice. Why? Because theory provides direction and without theory, practitioners would be setting sail without resources for navigation. In the end, you might find your way, but the trip would be shorter with GPS.

Counseling and psychotherapy theories are well-developed systems for understanding, explaining, predicting, and controlling human behavior. When someone on Twitter writes, “I have a theory that autism is caused by biological fathers who played too many computer games when they were children” it’s not a theory. More likely, it’s a thought or a guess or a goofy statement pertaining to that person’s idiosyncratic take on reality; it might be an effort to prove a point or sound clever, but it’s not a theory (actually, that particular idea isn’t even a good dissertation hypothesis).

Theories are foundations from which we build our understanding of human development, human suffering, self-destructive behavior, and positive change. Without theory, we can’t understand why people engage in self-destructive behaviors or why they sometimes stop being self-destructive. If we can’t understand why people behave in certain ways, then our ability to identify and apply effective treatments is compromised. In fact, every evidence-based or empirically supported approach rests on the shoulders of counseling and psychotherapy theory.

In life and psychotherapy, there are repeating patterns. I recall making an argument similar to Darrell’s while in graduate school. I complained to a professor that I wanted to focus on learning the essentials of becoming a great therapist. Her feedback was direct: I could become a technician who applied specific procedures to people or I could grapple with deeper issues and become a real therapist with a more profound understanding of human problems. If I chose the latter, then I could articulate the benefits and limitations of specific psychological change strategies and modify those strategies to fit unique and diverse clients.

Just like Darrell, my professor was biased, but in the opposite direction. She valued nuance, human mystery, and existential angst. She devalued what she viewed (at the time) as the superficiality of behavior therapy.

Both viewpoints have relevance to counseling and psychotherapy. We need technical skills for implementing research-based treatments, but we also need respect and empathy for idiosyncratic individuals who come to us for compassion and insight. We need the ability to view clients and problems from many perspectives—ranging from the indigenous to the contemporary medical model. To be proficient at applying specific technical skills, we need to understand the nuances and dynamics of psychotherapy and how human change happens. In the end, that means we need to study theories.

Contemporary Theories, Not Pop Psychology

Despite Darrell’s argument that traditional theories belong in the dumpster, all the theories in this text—even the old ones—are contemporary and relevant. They’re contemporary because they (a) have research support and (b) have been updated or adapted for working with diverse clients. They’re relevant because they include specific strategies and techniques that facilitate emotional, psychological, and behavioral change. Although some of these theories are more popular than others, they shouldn’t be confused with “pop” psychology.

Another reason these theories don’t belong in the dumpster is because their development and application include drama and intrigue that rival anything Hollywood has to offer. They include literature, myth, religion, and our dominant and minority political and social systems. They address and attempt to explain big issues, including:

  • How we define mental health.
  • Whether we believe in mental illness.
  • Views on love, meaning, death, and personal responsibility.
  • What triggers anger, joy, sadness, and depression.
  • Why trauma and tragedy strengthens some people, while weakening others.

There’s no single explanation for these and other big issues; often mental health professionals are in profound disagreement. Therefore, it should be no surprise that this book—a book about the major contemporary theories and techniques of psychotherapy and counseling—will contain controversy and conflict. We do our best to bring you more than just the theoretical facts; we also bring you the thrills and disappointments linked to contemporary theories of human motivation, functioning, and change.

Counseling and Psychotherapy Theory and Practice

What’s Your Theoretical Orientation?

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Corey Wubbolding and SF

On CESNET, several people asked about a “cheat sheet” to help students understand the distinctions between different counseling and psychotherapy theories,. Although many excellent options exist and some were offered up on CESNET, I’m adding mine here.

Here’s a Table with brief descriptions of each theory: Theoretical Orientation Summary Table

Here’s a short self-report “test” that students can take to self-identify their natural theoretical perspectives: What’s Your Theoretical Orientation – Short Questionnaire

I also have a longer self-report test that I can send you upon request. Just email me at john.sf@mso.umt.edu and I can send it along.

Thanks for your interest in counseling theories.

The files on this post are adapted from Chapter 1 (Psychotherapy and Counseling Essentials) of Counseling and Psychotherapy Theories in Context and Practice (2018, 3rd edition, John Wiley & Sons) by John and Rita Sommers-Flanagan.

You can request a free evaluation copy of the text through John Wiley & Sons: https://www.wiley.com/en-us/Counseling+and+Psychotherapy+Theories+in+Context+and+Practice%3A+Skills%2C+Strategies%2C+and+Techniques%2C+3rd+Edition-p-9781119279136

Counseling and Psychotherapy Theory and Practice

Thinking About Counseling and Psychotherapy Theories

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Theories III Photo

Definitions happen.

The process through which words and concepts are defined is fascinating. By definition, definitions need to be sharp and make distinctions, and yet they also sometimes be inclusive and blurry on the edges.

In the latest (3rd) edition of Counseling and Psychotherapy Theories in Context and Practice, Rita and I take aim at the definitions of counseling and psychotherapy. Read on, and if you’re inspired to do so, let me know what you think.

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Definitions of Counseling and Psychotherapy

Many students have asked us, “Should I get a PhD in psychology, a master’s degree in counseling, or a master’s in social work?”

This question usually brings forth a lengthy response, during which we not only explain the differences between these various degrees but also discuss additional career information pertaining to the PsyD degree, psychiatry, school counseling, school psychology, and psychiatric nursing. This sometimes leads to the confusing topic of the differences between counseling and psychotherapy. As time permits, we also share our thoughts about less-confusing topics, like the meaning of life.

Sorting out differences between mental health disciplines is difficult. Jay Haley (1977) was once asked: “In relation to being a successful therapist, what are the differences between psychiatrists, social workers, and psychologists?” He responded: “Except for ideology, salary, status, and power, the differences are irrelevant” (p. 165). Obviously, many different professional tracks can lead you toward becoming a successful mental health professional – despite a few ideological, salary, status, and power differences.

In this section we explore three confusing questions: What is psychotherapy? What is counseling? And what are the differences between the two?

What Is Psychotherapy?

Anna O., an early psychoanalytic patient of Josef Breuer (a mentor of Sigmund Freud), called her treatment the talking cure. This is an elegant, albeit vague, description of psychotherapy. Technically, it tells us very little but, at the intuitive level, it explains psychotherapy very well. Anna was saying something most people readily admit: talking, expressing, verbalizing, or sharing one’s pain and life story is potentially healing.

As we write today, heated arguments about how to practice psychotherapy continue (Baker & McFall, 2014; Laska, Gurman, & Wampold, 2014). This debate won’t soon end and is directly relevant to how psychotherapy is defined (Wampold & Imel, 2015). We explore dimensions of this debate in the pages to come. For now, keep in mind that although historically Anna O. viewed and experienced talking as her cure (an expressive-cathartic process), many contemporary researchers and writers emphasize that the opposite is more important – that a future Anna O. would benefit even more from listening to and learning from her therapist (a receptive-educational process). Based on this perspective, some researchers and practitioners believe therapists are more effective when they actively and expertly teach their clients cognitive and behavioral principles and skills (aka psychoeducation).

We have several favorite psychotherapy definitions:

  • A conversation with a therapeutic purpose (Korchin, 1976, p 281).
  • The purchase of friendship (Schofield, 1964, p. 1).
  • When one person with an emotional disorder gets help from another person who has a little less of an emotional disorder (J. Watkins, personal communication, October 13, 1983).

What Is Counseling?

Counselors have struggled to define their craft in ways similar to psychotherapists. Here’s a sampling:

  • Counseling is the artful application of scientifically derived psychological knowledge and techniques for the purpose of changing human behavior (Burke, 1989, p. 12).
  • Counseling consists of whatever ethical activities a counselor undertakes in an effort to help the client engage in those types of behavior that will lead to a resolution of the client’s problems (Krumboltz, 1965, p. 3).
  • [Counseling is] an activity … for working with relatively normal-functioning individuals who are experiencing developmental or adjustment problems (Kottler & Brown, 1996, p. 7).

We now turn to the question of the differences between counseling and psychotherapy.

What are the Differences Between Psychotherapy and Counseling?

Years ago, Patterson (1973) wrote: “There are no essential differences between counseling and psychotherapy” (p. xiv). We basically agree with Patterson, but we like how Corsini and Wedding (2000) framed it:

Counseling and psychotherapy are the same qualitatively; they differ only quantitatively; there is nothing that a psychotherapist does that a counselor does not do. (p. 2)

This statement implies that counselors and psychotherapists engage in the same behaviors—listening, questioning, interpreting, explaining, and advising—but may do so in different proportions.

The professional literature mostly implies that psychotherapists are less directive, go a little deeper, work a little longer, and charge a higher fee. In contrast, counselors are slightly more directive, work more on developmentally normal—but troubling—issues, work more overtly on practical client problems, work more briefly, and charge a bit less. In the case of individual counselors and psychotherapists, each of these tendencies may be reversed; some counselors work longer with clients and charge more, whereas some psychotherapists work more briefly with clients and charge less.

A Working Definition of Counseling and Psychotherapy

There are strong similarities between counseling and psychotherapy. Because the similarities vastly outweigh the differences we use the words counseling and psychotherapy interchangeably. Sometimes we use the word therapy as an alternative.

To capture the natural complexity of this thing called psychotherapy, we offer the following 12-part definition. Counseling or psychotherapy is:

(a) a process that involves (b) a trained professional who abides by (c) accepted ethical guidelines and has (d) competencies for working with (e) diverse individuals who are in distress or have life problems that led them to (f) seek help (possibly at the insistence of others) or they may be (g) seeking personal growth, but either way, these parties (h) establish an explicit agreement (informed consent) to (i) work together (more or less collaboratively) toward (j) mutually acceptable goals (k) using theoretically-based or evidence-based procedures that, in the broadest sense, have been shown to (l) facilitate human learning or human development or reduce disturbing symptoms.

Although this definition is long and multifaceted, it’s still probably insufficient. For example, it wouldn’t fit for any self-administered forms of therapy, such as self-analysis or self-hypnosis—although we’re quite certain that if you read through this definition several times, you’re likely to experience a self-induced hypnotic trance state.

*To learn more about our Counseling and Psychotherapy Theories text, all you have to do is Google it. If you’re looking for an instructor’s copy, Google the book title and then go to the Wiley website and request one. If you have troubles with that, email me . . . and I can likely help out.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Separating the Psychological (Emotional) Pain from the Self: A Technique for Working with Suicidal Clients

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Blogs I follow

I’m working on a Suicide Assessment and Treatment Planning manuscript and here’s a small piece of what I just wrote:

Rosenberg (1999; 2000) and others have described a helpful cognitive reframe intervention for use with clients who are suicidal. She wrote,

The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self (1999, p. 86).

Shneidman’s (1996) guidance on this was similar, but perhaps even more emphatic. He recommended that therapists partner with clients and with members of the client’s support system (e.g., family) to do whatever possible to reduce the psychological pain.

Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit (p. 139).

Suicidal clients need empathy for their emotional pain, but they also need to partner with therapists to fight against their pain. Framing the pain as separate from the self can help because therapists can be empathic, but simultaneously illuminate the possibility that the wish isn’t to eliminate the self, but instead, to eliminate the pain.

Rosenberg (1999) also recommended that therapists help clients reframe what’s usually meant by the phrase feeling suicidal. She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the therapist’s empathic message.

Here’s a case vignette to illustrate how therapists can work with clients to separate the emotional pain from the self and then partner with clients to reduce the pain. As always, this case vignette is a composite compiled from clinical work and simulations with various individuals.

Case Vignette. Kate is a 44-year-old cisgender married female with two children. She arrived for counseling in extreme emotional distress. She was also agitated, stating, “It just hurts so badly to be alive. It hurts so badly.”

Much of Kate’s emotional pain was centered around the recent death of her mother, whom Kate had cared for over the past seven years. Kate had an ambivalent relationship with her; her mother had been diagnosed as having schizophrenia and caring for her was extremely challenging. Kate’s acute emotional distress was accompanied by fears of turning out like her mother and thoughts of reunifying with her mother. She said, “I just need to be with her.”

To help Kate separate her intense emotional pain from the self, I began by noticing that there were two different parts of Kate, and that these two different parts had different ideas about how to move forward. Noticing and articulating different perspectives of the self is a common approach from a person-centered theoretical perspective. Because of Kate’s family history of schizophrenia, I wouldn’t use an expressive Gestalt technique to separate her different ego states, but it felt like reflecting her obvious ambivalence was a safe approach. Specifically, I said, “Sounds like a part of yourself thinks the solution is to die, and that your kids will be better off. But there’s another part of you that says, maybe the solution isn’t to die. Maybe I can come in here and talk. Maybe my kids actually would suffer if I died.”

Kate accepted that she was “of two minds” about how to go forward. Next, I tried to further clarify these parts of herself, emphasizing that I wanted to align with the “second” part of herself, so that we could work together on her emotional pain.

The one part of yourself thinks your only hope of dealing with the pain is to kill yourself. The other part thinks, maybe I can stay alive, work in counseling to get rid of the pain, and then my children wouldn’t suffer from my death. How about, for now, we work from that second perspective. We can be a team that works hard to decrease the emotional pain you’re feeling. It might not go away immediately, but if you stay alive and we work together, we can chip away at the pain and make it shrink.

You may notice the words I used were somewhat redundant. Using redundancy with clients who are feeling suicidal may be needed because the agitated, depressed state of mind makes cognitive focusing difficult. Sometimes, if you don’t repeat the therapeutic perspective and keep focused on it, the therapeutic perspective can slip away from your clients’ cognitive grasp.

Linehan often uses a more provocative way of talking about partnering with clients to diminish their pain. For example, she might say, “Getting through this is like going through Hell. But I know therapy can help and I want to work with you on this. But I have to tell you this, therapy will only work if you stay alive. Therapy doesn’t work on dead people. So I want you to stay alive and work with me at attacking your pain. Will you give me six months for us to go through hell together so we can get control of your pain?”

Either way, the goal is to partner with clients to work on decreasing emotional or psychological pain. This approach combines empathic listening, with an emphasis on the therapeutic alliance. As therapist and client partner together, then cognitive-behavioral problem-solving can commence.

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Parenting, Tough Kids, Tough Kids Cool Counseling

Using Therapeutic Storytelling with Children: Five Easy Steps

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Books

Everybody loves a good story.

Good stories grab the listener’s attention and don’t let go. I’ve been reading and telling stories for as long as I can remember. Whether its kindergartners, clients, or college students, I’ve found that stories settle people into a receptive state that looks something like a hypnotic trance.

Nowadays, mostly we see children and teens entranced with their electronic devices, television, and movies. Although it’s nice to see young people in a calm and focused state, the big problem with devices (other than their negative effects on sleep, attention span, weight, brain development, and nearly everything else having to do with living in the real world), is that we (parents, caretakers, and concerned adults), don’t have control over the electronic stories our children see and hear.

Storytelling is a natural method for teaching and learning. Children learn from stories. We’re teaching when we tell them. We might as well add our intentional selection of stories to whatever our children might be learning from the internet.

Way back in 1997, Rita and I wrote a book called Tough Kids, Cool Counseling. One of the chapters focused on how to use therapeutic storytelling with children and teens. Although the content of Tough Kids, Cool Counseling is dated, the ideas are still solid. The following section is good material for counselors, psychotherapists, parents, and other adults who want to influence young people.

In counseling, storytelling was originally developed as a method for bypassing client resistance. Stories are gentle methods that don’t demand a response, but that stimulate, “thinking, experiencing, and ideas for problem resolution” (Lankton & Lankton, 1989, pp. 1–2)

Storytelling is an alternative communication strategy. For counselors, it should be used as a technique within the context of an overall treatment plan, rather than as a treatment approach in and of itself. For parents and caregivers, stories should be fun, and engaging . . . and told in ways that facilitate learning.

Story construction. Even if you’re an excellent natural storyteller, it can help to have a guide or structure for story construction and development. I like using a framework that Bill Cook, a Montana psychologist, wrote about and shared with me. He uses the acronym S-T-O-R-I, to organize the parts of a therapeutic story.

S: Set the stage for the story. To set the stage, you should create a scenario that focuses on a child living in a particular situation. The child can be a human or an animal or an animated object. The central child character should be described in a way that’s positive and appealing. Because much of my work back in the 1990s involved working with boys who were angry and impulsive, the following story features a boy who has an arguing problem. Depending on your circumstances, you could easily feature a girl or a child who doesn’t have a particular gender identity.

Here’s the beginning of the story.

Once upon a time there was a really smart boy. His name was Lancaster. Lancaster was not only smart, he was also a very cool dresser. He wore excellent clothes and most everyone who met Lancaster immediately was impressed with him. Lancaster lived with his mother and sister in the city.

In this example, the client’s name was Larry. If it’s not too obvious, you can give the central character a name that sounds similar to your client’s name. You may also develop a story that has other similarities to your client’s life.

T: Tell about the problem. This stage includes a problem with which the central character is struggling. It should be a problem similar to your client’s or your child’s. This stage ends with a statement about how no one knows what to do about this very difficult and perplexing problem.

Every day, Lancaster went to school. He went because he was supposed to, not because he liked school. You see, Lancaster didn’t like having people tell him what to do. He liked to be in charge. He liked to be the boss. The bad news is that his teachers at school liked to be in charge too. And when he was at home, his mother liked to be the boss. So Lancaster ended up getting into lots of arguments with his teachers and mother. His teachers were very tired of him and about to kick him out of school. To make things even worse, his mother was so mad at him for arguing all the time that she was just about to kick him out of the house. Nobody knew what to do. Lancaster was arguing with everyone and everyone was mad at Lancaster. This was a very big problem.

O: Organize a search for helpful resources. During this part of the story, the central character and family try to find help to solve the problem. This search usually results in identifying a wise old person or animal or alien creature as a special helper. The wise helper lives somewhere remote and has a kind, gentle, and mysterious quality. In this case, because Larry (the client) didn’t have many positive male role models in his life, I chose to make the wise helper a male. Obviously, you can control that part of the story to meet the child’s needs and situation.

Because the situation kept getting worse and worse and worse, almost everyone had decided that Lancaster needed help—except Lancaster. Finally, Lancaster’s principal called Lancaster’s mom and told her of a wise old man who lived in the forest. The man’s name was Cedric and, apparently, in the past, he had been helpful to many young children and their families. When Lancaster’s mother told him of Cedric, Lancaster refused to see Cedric. Lancaster laughed and sneered and said: “The principal is a Cheese-Dog. He doesn’t know the difference between his nose and a meteorite. If he thinks it’s a good idea, I’m not doing it!”

But eventually Lancaster got tired of all the arguing and he told his mom “If you buy me my favorite ice cream sundae every day for a week, I’ll go see that old Seed-Head man. Lancaster’s mom pulled out her purse and asked, “What flavor would you like today?”

After hiking 2 hours through the forest, they arrived at Cedric’s tree house late Saturday morning. They climbed the steps and knocked. A voice yelled: “Get in here now, or the waffles will get cold!” Lancaster and his mom stepped into the tree house and were immediately hit with a delicious smell. Cedric waved to them like old friends, had them sit at the kitchen table, a served them a stack of toasty-hot strawberry waffles, complete with whipped cream and fresh maple syrup. They ate and talked about mysteries of the forest. Finally, Cedric leaned back, and asked, “Now what do you two want . . . other than my strawberry waffles and this pleasant conversation?”

Lancaster suddenly felt shy. His mom, being a sensitive mom, looked up at Cedric’s big hulking face and described how Lancaster could argue with just about anyone, anytime, anywhere. She described his tendency to call people mean names and mentioned that Lancaster was in danger of being kicked out of school. Of course, Lancaster occasionally burst out with: “No way!” and “I never said that,” and even an occasional, “You’re stupider than my pet toad.”

After Lancaster’s mom stopped talking, Cedric looked at Lancaster. He grinned and chuckled. Lancaster didn’t like it when people laughed at him, so he asked, “What are YOU laughing about?” Cedric replied, “I like that line. You’re even stupider than my pet toad. You’re funny. I’m gonna try that one out. How about if we make a deal? Both you and I will say nothing but “You’re even stupider than my pet toad” in response to everything anyone says to us. It’ll be great. We’ll have the most fun this week ever. Okay. Okay. Make me a deal.” Cedric reached out his hand.

Lancaster was confused. He just automatically reached back and said, “Uh, sure.”

Cedric quickly stood up and motioned Lancaster and his mom to the door, smiling and saying, “Hey you two toad-brains, see you next Saturday!!”

Searching for helpful resources can be framed in many ways. For counselors, you might construct it to be similar to what children and parents experience during their search for a counselor. Consistent with the classic Mrs. Piggle Wiggle book series, the therapeutic helper in the story has tremendous advantages over ordinary counselors. In the Lancaster example, Cedric gets to propose a maladaptive and paradoxical strategy without risk, because the whole process is simply a thought experiment. Depending on your preference and situation, you can use whatever “treatment” strategy you like.

R: Refine the therapeutic intervention. In this storytelling model, the initial therapeutic strategy isn’t supposed to be effective. Instead, the bad strategy that Cedric proposes is designed for a core learning experience. During the fourth stage (refinement) the central character learns an important lesson and begins the behavior change process.

Both Lancaster and Cedric had a long week. They called everyone they saw a “stupid toad-brain” and said, “You’re even stupider than my pet toad” and the results were bad. Lancaster got kicked out of school. That morning, when they were on their way to Cedric’s, Lancaster got slugged in the mouth for insulting their taxi driver and he was sporting a fat lip.

When Lancaster stepped into Cedric’s tree house, he noticed that Cedric had a black eye.

“Hey, Mr. Toad-Brain, what happened to your eye?” asked Lancaster. “Probably the same thing that happened to your face, fish lips!” replied Cedric.

Lancaster and Cedric sat staring at each other in awkward silence. Lancaster’s mom decided to just sit quietly to see what would happen. She felt surprisingly entertained.

Cedric broke the silence. “Here’s what I think. I don’t think everyone appreciates our humor. In fact, nobody I met liked the idea of having their brain compared to your pet toad’s brain. They never even laughed once. Everybody got mad at me. Is that what things are usually like for you?”

Lancaster muttered back, “Uh, well, yeah.” But this week was worse. My best friend said he doesn’t want to be best friends and my principal got so mad at me that he put my head in the toilet of the boys’ bathroom and flushed it.”

Cedric rolled his eyes and laughed, “And I thought I had a bad week. Well, Lanny, mind if I call you Lanny?”

“Yeah, whatever, Just don’t call me anything that has to do with toads.”

“Well Lanny, the way I see it, we have three choices. First, we can keep on with the arguing and insulting. Maybe if we argue even harder and used different insults, people will back down and let us have things our way. Second, we can work on being really nice to everyone most of the time, so they’ll forgive us more quickly when we argue with them in our usual mean and nasty way. And third, we can learn to argue more politely, so we don’t get everyone upset by calling them things like ‘toad brains’ and stuff like that.”

After talking their options over with each other and with Lancaster’s mom, Cedric and Lancaster decided to try the third option: arguing more politely. In fact, they practiced with each other for an hour or so and then agreed to meet again the next week to check on how their new strategy worked. Their practice included inventing complimentary names for each other like “Sweetums” or “Tulip” and surprising people with positive responses like, “You’re right!” or “Yes boss, I’m on it!”

As seen in the narrative, Lanny and Cedric learn lessons together. The fact that they learn them together is improbable in real life. However, the storytelling modality allows counselor and client the opportunity to truly form a partnership and enact Aaron Beck’s concept of collaborative empiricism.

I: Integrating the lesson. In the final stage of this storytelling model, the central character articulates the lesson(s) learned.

Months later, Lancaster got an invitation from Cedric for an ice cream party. When Lancaster arrived, he realized the party was just for him and Cedric. Cedric held up his glass of chocolate milk and offered a toast. He said, “To my friend Lanny. I could tell when I first met you that you were very smart. Now, I know that you’re not only smart, but you are indeed wise. Now, you’re able to argue politely and you only choose to argue when you really feel strongly about something. You’re also as creative in calling people nice names as you were at calling them nasty names. And you’re back in school and, as far as I understand, your life is going great. Thanks for teaching me a memorable lesson.”

As Lanny raised his glass for the toast, he noticed how strong and good he felt. He had learned when to argue and when not to argue. But even more importantly, he had learned how to say nice things to people and how to argue without making everyone mad at him. The funny thing was, Lanny felt happier. Mostly, all those mad feelings that had been inside him weren’t there anymore.

At the end of this story (or whatever story you decide to use), you can directly discuss the “moral of the story” or just leave it hanging. In many cases, leaving the story’s message unstated is useful. Alternatively, you might ask the child, “What do you think of this story?”

Letting the child consider the message provides an opportunity for intellectual stimulation and may aid in moral development. Although it would be nice to claim that therapeutic storytelling causes immediate behavior change, the more important outcome is that storytelling provides a way for an adult and a child to have pleasant interactions around a story . . . with the possibility that, over time, positive behavior change may occur.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention, Writing

Suicide Myths — Part Two

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From M 2019 Spring

This is part two of my “Four Suicide Myths” blog post. If you read part one, you probably noticed that it ended abruptly. Apparently, that’s how I do two-part blog posts. Thinking back, I should have added something like, “end of part one.” 

And so, as an introduction, here’s the beginning of part two . . .

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.” Additionally, the rates of suicidal thinking among high school and college students is so high (estimates of 20-40% annual incidence) that it’s more appropriate to label suicidal thoughts as common, rather than a sign of deviance or illness.

Edwin Shneidman—the American “Father” of suicidology—denied a relationship between suicide and so-called mental illness in the 1973 Encyclopedia Britannica, stating succinctly:

“Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although . . . it has often been so treated in Western and other cultures).”

A recent report from the U.S. Centers for Disease Control (CDC) supported Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder. Keep in mind that the CDC wasn’t focusing on people who think about or attempt suicide; their study focused only on individuals who died by suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), meet diagnostic criteria for a mental disorder.  As one of my mentors used to say, “Having the thought of suicide is not dangerous and is not the problem.”

Truth #2: Suicidal thoughts are not—in and of themselves—a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress.

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

In 1995, renowned suicidologist, Robert Litman wrote:

At present it is impossible to predict accurately any person’s suicide. Sophisticated statistical models . . . and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient commits suicide while nine other equally depressed and equally suicidal patients do not, I answer, “I don’t know.” (p. 135)

Litman’s comments remain true today. Part of the problem stems from the fact that suicide is what is referred to as a low base rate event. When something occurs at a low base rate, it becomes mathematically very difficult to predict. Suicide is a prime example of a low base rate event. According to the CDC, in 2017, only about 14 of every 100,000 citizens died by suicide.

Imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 14 of the 100,000 fans will die by suicide over the next 365 days.

A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that every one of the 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide) and ask them to leave the stadium. Now you’re down to identifying which 14 of 15,000 will die by suicide.

For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.

At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive psychological treatment for the remaining 7,500 people. However, many of the fans will refuse treatment, including some of whom will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.

To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 14 individuals who will die by suicide over the next year. All this points to the magnitude of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people some of the time.

Truth #4: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research doesn’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, odds are, in the vast majority of cases, you won’t be able to efficiently predict or prevent suicide attempts or suicide deaths.

Myth #4: Suicide prevention and intervention should focus on eliminating suicidal thoughts.

Logical analysis implies that if suicidal thoughts within an individual are eliminated, then suicide will be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy? The first reason is because most people who think about suicide never make a suicide attempt. But that’s only the tip of the iceberg.

After his son died by suicide, Rick Warren, a famous pastor and author, created a Youtube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads, “If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!”

Although over 1,000 viewers clicked on the “thumbs up” sign for the video, there were 535 comments; these comments mostly pushed back on Pastor Warren’s well-intended message. Examples included:

  • Are you kidding me??? You’ve clearly never been suicidal or really depressed.
  • To say “Suicide is a permanent solution to a temporary problem” is like saying: “You couldn’t possibly have suffered long enough, even if you’ve suffered your entire life from many, many issues.”
  • This is extremely disheartening. With all due respect. Pastor, you just don’t get it.

Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, most of us try to use rational persuasion to encourage individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called psychological reactance helps explain why rational persuasion—even when well-intended—rarely makes for an effective intervention.

While working with chronically suicidal patients for over two decades, Dr. Marsha Linehan of the University of Washington made an important discovery: when psychotherapists try to get their patients to stop thinking about suicide, the opposite usually happens—the patients become more suicidal.

Linehan’s discovery has played out in my clinical practice. Nearly every time I’ve actively pushed clients to stop thinking about suicide—using various psychological ploys and techniques—my efforts have backfired.

Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective.

Starting Over

Individuals who are suicidal are complex, unique, and in deep distress. Judging them as ill is unhelpful. Believing that we can successfully predict and prevent suicide borders on delusional. Direct persuasion usually backfires. Letting go of the four common suicide myths might make you feel nervous. At least they provided guidance for action, right? But just like having the female on top to prevent pregnancy, clinging to unhelpful myths won’t, in the end, be effective. How do we start over? Where do we go from here?

All solutions—or at least most of them—begin with a clear understanding of the problem. As someone who has worked directly with suicidal individuals for decades, there’s no better person to start us on the journey toward a deeper understanding of suicide than Dr. Marsha Linehan.

Dr. Linehan is the developer of dialectical behavior therapy (DBT for short). DBT is widely hailed as the most effective evidence-based approach for working with chronically suicidal patients. To help her students at the University of Washington better understand the dynamics of suicide, Dr. Linehan begins her teaching with this story:

The suicidal person [is] trapped in a small, dark room with no windows and high walls (in my mind always with stark white walls reaching very, very high). The room is excruciatingly painful. The person searches for a door out to a life worth living but, alas, cannot find it. Scratching and clawing on the walls does no good. Screaming and banging brings no help. Falling to the floor and trying to shut down and feel nothing gives no relief. Praying to God and all the saints one knows brings no salvation. The only door out the individual can find is the door to death. The task of the therapist in this situation, as I always tell my clients also, is to somehow find a way to get into the room with the person, to see the person’s world from his or her point of view; to get inside the person, so to speak, and then together search again for that door to life that the therapist knows must be there.

Efforts to understand someone else’s reality are destined to fall short. You can’t always get it right, but that’s okay, because empathy is more about being with and feeling with others, than it is about perfectly understanding them. Trying to understand the inner world of others is an act of courage and compassion. Thus, our next step is to suspend judgment and begin our descent into that small, dark room with no windows.