Category Archives: Personal Reflections

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Research

Today’s Rabbit Hole: What Constitutes Scientific Evidence for Psychotherapy Efficacy?

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On July 24, in Helena, I attended a fun and fascinating meeting sponsored by the Carter Center. I spent the day with a group of incredibly smart people dedicated to improving mental health in Montana.

The focus was twofold. How do we promote and establish mental health parity in Montana and how do with improve behavioral health in schools? Two worthy causes. The discussions were enlightening.

We haven’t solved these problems (yet!). In the meantime, we’re cogitating on the issues we discussed, with plans to coalesce around practical strategies for making progress.

During our daylong discussions, the term evidence-based treatments bounced around. I shared with the group that as an academic psychologist/counselor, I could go deep into a rabbit-hole on terminology pertaining to treatment efficacy. Much to everyone’s relief, I exhibited a sort of superhuman inhibition and avoided taking the discussion down a hole lined with history and trivia. But now, much to everyone’s delight (I’m projecting here), I’m sharing part of my trip down that rabbit hole. If exploring the use of terms like, evidence-based, best practice, and empirically supported treatment is your jam, read on!

The following content is excerpted from our forthcoming text, Counseling and Psychotherapy Theories in Context and Practice (4th edition). Our new co-author is Bryan Cochran. I’m reading one of his chapters right now . . . which is so good that you all should read it . . . eventually. This text is most often used with first-year students in graduate programs in counseling, psychology, and social work. Consequently, this is only a modestly deep rabbit hole.

Enjoy the trip.

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What Constitutes Evidence? Efficacy, Effectiveness, and Other Research Models

We like to think that when clients or patients walk into a mental health clinic or private practice, they will be offered an intervention that has research support. This statement, as bland as it may seem, would generate substantial controversy among academics, scientists, and people on the street. One person’s evidence may or may not meet another person’s standards. For example, several popular contemporary therapy approaches have minimal research support (e.g., polyvagal theory and therapy, somatic experiencing therapy).

Subjectivity is a palpable problem in scientific research. Humans are inherently subjective; humans design the studies, construct and administer assessment instruments, and conduct the statistical analyses. Consequently, measuring treatment outcomes always includes error and subjectivity. Despite this, we support and respect the scientific method and appreciate efforts to measure (as objectively as possible) psychotherapy outcomes.

There are two primary approaches to outcomes research: (1) efficacy research and (2) effectiveness research. These terms flow from the well-known experimental design concepts of internal and external validity (Campbell et al., 1963). Efficacy research employs experimental designs that emphasize internal validity, allowing researchers to comment on causal mechanisms; effectiveness research uses experimental designs that emphasize external validity, allowing researchers to comment on generalizability of their findings.

Efficacy Research

Efficacy research involves tightly controlled experimental trials with high internal validity. Within medicine, psychology, counseling, and social work, randomized controlled trials (RCTs) are the gold standard for determining treatment efficacy. RCTs statistically compare outcomes between randomly assigned treatment and control groups. In medicine and psychiatry, the control group is usually administered an inert placebo (i.e., placebo pill). In the end, treatment is considered efficacious if the active medication relieves symptoms, on average, at a rate significantly higher than placebo. In psychotherapy research, treatment groups are compared with a waiting list, attention-placebo control group, or alternative treatment group.

To maximize researcher control over independent variables, RCTs require that participants meet specific inclusion and exclusion criteria prior to random assignment to a treatment or comparison group. This allows researchers to determine with greater certainty whether the treatment itself directly caused treatment outcomes.

In 1986, Gerald Klerman, then head of the National Institute of Mental Health, gave a keynote address to the Society for Psychotherapy Research. During his speech, he emphasized that psychotherapy should be evaluated through RCTs. He claimed:

We must come to view psychotherapy as we do aspirin. That is, each form of psychotherapy must have known ingredients, we must know what these ingredients are, they must be trainable and replicable across therapists, and they must be administered in a uniform and consistent way within a given study. (Quoted in Beutler, 2009, p. 308)

Klerman’s speech advocated for medicalizing psychotherapy. Klerman’s motivation for medicalizing psychotherapy partly reflected his awareness of heated competition for health care dollars. This is an important contextual factor. Events that ensued were an effort to place psychological interventions on par with medical interventions.

The strategy of using science to compete for health care dollars eventually coalesced into a movement within professional psychology. In 1993, Division 12 (the Society of Clinical Psychology) of the American Psychological Association (APA) formed a “Task Force on Promotion and Dissemination of Psychological Procedures.” This task force published an initial set of empirically validated treatments. To be considered empirically validated, treatments were required to be (a) manualized and (b) shown to be superior to a placebo or other treatment, or equivalent to an already established treatment in at least two “good” group design studies or in a series of single case design experiments conducted by different investigators (Chambless et al., 1998).

Division 12’s empirically validated treatments were instantly controversial. Critics protested that the process favored behavioral and cognitive behavioral treatments. Others complained that manualized treatment protocols destroyed authentic psychotherapy (Silverman, 1996). In response, Division 12 held to their procedures for identifying efficacious treatments but changed the name from empirically validated treatments to empirically supported treatments (ESTs).

Advocates of ESTs don’t view common factors in psychotherapy as “important” (Baker & McFall, 2014, p. 483). They view psychological interventions as medical procedures implemented by trained professionals. However, other researchers and practitioners complain that efficacy research outcomes do not translate well (aka generalize) to real-world clinical settings (Hoertel et al., 2021; Philips & Falkenström, 2021).

Effectiveness Research

Sternberg, Roediger, and Halpern (2007) described effectiveness studies:

An effectiveness study is one that considers the outcome of psychological treatment, as it is delivered in real-world settings. Effectiveness studies can be methodologically rigorous …, but they do not include random assignment to treatment conditions or placebo control groups. (p. 208)

Effectiveness research focuses on collecting data with external validity. This usually involves “real-world” settings. Effectiveness research can be scientifically rigorous but doesn’t involve random assignment to treatment and control conditions. Inclusion and exclusion criteria for clients to participate are less rigid and more like actual clinical practice, where clients come to therapy with a mix of different symptoms or diagnoses. Effectiveness research is sometimes referred to as “real world designs” or “pragmatic RCTs” (Remskar et al., 2024). Effectiveness research evaluates counseling and psychotherapy as practiced in the real world.

Other Research Models

Other research models also inform researchers and practitioners about therapy process and outcome. These models include survey research, single-case designs, and qualitative studies. However, based on current mental health care reimbursement practices and future trends, providers are increasingly expected to provide services consistent with findings from efficacy and effectiveness research (Cuijpers et al., 2023).

In Pursuit of Research-Supported Psychological Treatments

Procedure-oriented researchers and practitioners believe the active mechanism producing positive psychotherapy outcomes is therapy technique. Common factors proponents support the dodo bird declaration. To make matters more complex, prestigious researchers who don’t have allegiance to one side or the other typically conclude that we don’t have enough evidence to answer these difficult questions about what ingredients create change in psychotherapy (Cuijpers et al., 2019). Here’s what we know: Therapy usually works for most people. Here’s what we don’t know: What, exactly, produces positive changes.

For now, the question shouldn’t be, “Techniques or common factors?” Instead, we should be asking “How do techniques and common factors operate together to produce positive therapy outcomes?” We should also be asking, “Which approaches and techniques work most efficiently for which problems and populations?” To be broadly consistent with the research, we should combine principles and techniques from common factors and EST perspectives. We suspect that the best EST providers also use common factors, and the best common factors clinicians sometimes use empirically supported techniques.

Naming and Claiming What Works

When it comes to naming and claiming what works in psychotherapy, we have a naming problem. Every day, more research information about psychotherapy efficacy and effectiveness rolls in. As a budding clinician, you should track as much of this new research information as is reasonable. To help you navigate the language of researchers and practitioners use to describe “What works,” here’s a short roadmap to the naming and claiming of what works in psychotherapy.

When Klerman (1986) stated, “We must come to view psychotherapy as we do aspirin” his analogy was ironic. Aspirin’s mechanisms and range of effects have been and continue to be complex and sometimes mysterious (Sommers-Flanagan, 2015). Such is also the case with counseling and psychotherapy.

Language matters, and researchers and practitioners have created many ways to describe therapy effectiveness.

  • D12 briefly used the phrase empirically validated psychotherapy. Given that psychotherapy outcomes vary, the word validated is generally avoided.
  • In the face of criticism, D12 blinked once, renaming their procedures as empirically supported psychotherapy. ESTs are manualized and designed to treat specific mental disorders or specific client problems. If it’s not manualized and doesn’t target a disorder/problem, it’s not an EST.
  • ESTs have proliferated. As of this moment (August 2025), 89 ESTs for 30 different psychological disorders and behavior problems are listed on the Division 12 website (https://div12.org/psychological-treatments/). You can search the website to find the research status of various treatments.
  • To become proficient in providing an EST requires professional training. Certification may be necessary. It’s impossible to obtain training to implement all the ESTs available.
  • In 2006, an APA Presidential Task Force (2006) loosened D12’s definition, shifting to a more flexible term, Evidence-Based Practice (EBP), and defining it as ‘‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences’’ (p. 273).
  • In 2007, the Journal of Counseling and Development, the American Counseling Association’s flagship journal, inaugurated a new journal section, “Best Practices.” As we’ve written elsewhere, best practice has grown subjective and generic and is “often used so inconsistently that it is nearly meaningless” (Sommers-Flanagan, 2015, p. 98).
  • In 2011, D12 relaunched their website, relabeling ESTs as research-supported psychological treatments (n.b., most researchers and practitioners continue to refer to ESTs instead of research-supported psychological treatments).
  • As an alternative source of research updates, you can also track the prolific work of Pim Cuijpers and his research team for regular meta-analyses on psychological treatments (Cuijpers et al., 2023; Harrer et al., 2025).
  • Other naming variations, all designed to convey the message that specific treatments have research support, include evidence-based treatment, evidence-supported treatment, and other phrasings that, in contrast to ESTs and APA’s evidence-based practice definition, have no formal definition.

Manuals, Fidelity, and Creativity

Manualized treatments require therapist fidelity. In psychotherapy, fidelity means exactness or faithfulness to the published procedure—meaning you follow the manual. However, in the real world, when it comes to treatment fidelity, therapist practice varies. Some therapists follow manuals to the letter. Others use the manual as an outline. Still others read the manual, put it aside, and infuse their therapeutic creativity.

A seasoned therapist (Bernard) we know recently provided a short, informal description of his application of exposure therapy to adult and child clients diagnosed with obsessive-compulsive disorder. Bernard described interactions where his adult clients sobbed with relief upon getting a diagnosis. Most manuals don’t specify how to respond to clients sobbing, so he provided empathy, support, and encouragement. Bernard described a therapy scenario where the client’s final exposure trial involved the client standing behind Bernard and holding a sharp kitchen knife at Bernard’s neck. This level of risk-taking and intimacy also isn’t in the manual—but Bernard’s client benefited from Bernard trusting him and his impulse control.

During his presentation, Bernard’s colleagues chimed in, noting that Bernard was known for eliciting boisterous laughter from anxiety-plagued children and teenagers. There’s no manual available on using humor with clients, especially youth with overwhelming obsessional anxiety. Bernard used humor anyway. Although Bernard had read the manuals, his exposure treatments were laced with empathy, creativity, real-world relevance, and humor. Much to his clients’ benefit, Bernard’s approach was far outside the manualized box (B. Balleweg, personal communication, July 14, 2025).    

As Norcross and Lambert (2018) wrote: “Treatment methods are relational acts” (p. 5). The reverse is equally applicable, “Relational acts are treatment methods.” As you move into your therapeutic future, we hope you will take the more challenging path, learning how to apply BOTH the techniques AND the common factors. You might think of this—like Bernard—as practicing the science and art of psychotherapy.

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Note: This is a draft excerpt from Chapter 1 of our 4th edition, coming out in 2026. As a draft, your input is especially helpful. Please share as to whether the rabbit hole was too deep, not deep enough, just right, and anything else you’re inspired to share.

Thanks for reading!

Happiness, Love, Personal Reflections, Writing

Come Join Us in Early August in Billings Montana for a Workshop on Happiness for Educators

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A friend and colleague in the Counseling Department at the University of Montana forwarded me an article by Lucy Foulkes of Oxford University titled, “Mental-health lessons in schools sound like a great idea. The trouble is, they don’t work.”

That is troubling. My friend knows I’ve been thinking about these things for years . . . and I feel troubled about it too.

Children’s behavioral or mental or emotional health has been in decline for decades. COVID made things worse. Even at the University, our collective impression is that current students—most of whom are simply fantastic—are more emotionally fragile than we’ve ever seen before.

As Craig Bryan says in his remarkable book, “Rethinking Suicide,” big societal problems like suicide, homelessness, addiction, and mental health are “wicked problems” that often respond to well-intended efforts by not responding, or by getting worse.

Such is the case that Lisa Foulkes is describing in her article.  

I’ve had a front row seat to mental health problems getting worse for about 42 years now. Oh my. That’s saying something. Mostly it’s saying something about my age. But other than my frightening age, my point is that in my 42+ years as a mental health professional, virtually everything in the mental health domain has gotten worse. And when I say virtually, I mean literally.

Anxiety is worse. Depression is worse. ADHD is worse, not to mention bipolar, autism spectrum disorder, suicide, and spectacular rises in trauma. I often wonder, given that we have more evidence-based treatments than ever before in the history of time . . . and we have more evidence-based mental health prevention programming than ever before in the history of time . . . how could everything mental health just keep on going backward? The math doesn’t work.

In her article, Lisa Foulkes points out that mental health prevention in schools doesn’t work. To me, this comes as no big surprise. About 10 years ago, mental health literacy in schools became a big deal. I remember feeling weird about mental health literacy, partly because across my four decades as an educator, I discovered early on that if I presented the diagnostic criteria for ADHD to a class of graduate students, about 80% of them would walk away thinking they had ADHD. That’s just the way mental health literacy works. It’s like medical student’s disease; the more you learn about what might be wrong with you the more aware and focused you become on what’s wrong with you. We’ve known this since at least the 1800s.

But okay, let’s teach kids about mental health disorders anyway. Actually, we’re sort of trapped into doing this, because if we don’t, everything they learn will be from TikTok. . . which will likely generate even worse outcomes.

I’m also nervous about mindful body scans (which Foulkes mentions), because they nearly always backfire as well. As people scan their bodies what do they notice? One thing they don’t notice is all the stuff that’s working perfectly. Instead, their brains immediately begin scrutinizing what might be wrong, lingering on a little gallop in their heart rhythm or a little shortness of breath or a little something that itches.

Not only does mental health education/prevention not work in schools, neither does depression screenings or suicide screenings. Anyone who tells you that any of these programs produces large and positive effects is either selling you something, lying, or poorly informed. Even when or if mental health interventions work, they work in small and modest ways. Sadly, we all go to bed at night and wake up in the morning with the same brain. How could we expect large, dramatic, and transformative positive outcomes?

At this point you—along with my wife and my team at the Center for the Advancement of Positive Education—may be thinking I’ve become a negative-Norman curmudgeon who scrutinizes and complains about everything. Could be. But on my good days, I think of myself as a relatively objective scientist who’s unwilling to believe in any “secret” or public approaches that produce remarkably positive results. This is disappointing for a guy who once hoped to develop psychic powers and skills for miraculously curing everyone from whatever ailed them. My old college roommate fed my “healer” delusions when, after being diagnosed with MS, “I think you’ll find the cure.”

The painful reality was and is that I found nothing helpful about MS, and although I truly believe I’ve helped many individuals with their mental health problems, I’ve discovered nothing that could or would change the negative trajectory of physical or mental health problems in America. These days, I cringe when anyone calls themselves a healer. [Okay. That’s likely TMI.]

All this may sound ironic coming from a clinical psychologist and counselor educator who consistently promotes strategies for happiness and well-being. After what I’ve written above, who am I to recommend anything? I ask that question with full awareness of what comes next in this blog. Who am I to offer guidance and educational opportunities? You decide. Here we go!

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The Center for the Advancement of Positive Education (CAPE) and the Montana Happiness Project (that means me and my team) are delighted to be a part of the upcoming Jeremy Bullock Safe Schools Conference in Billings, MT. The main conference will be Aug 5-6. You can register for the conference here: https://jeremybullocksafeschools.com/register. The flyer with a QR code is here:

2025 Flyer_J BullockDownload

In the same location, beginning on the afternoon of Aug 6 and continuing for most of Aug 7, CAPE is offering a “Montana Happiness” infused 7-hour bonus training. Using our combined creative skills, we’ve decided to call our workshop: “Happiness for Educators.” Here’s the link to sign up for either a one-credit UM grad course (extra work is required) or 7 OPI units: https://www.campusce.net/umextended/course/course.aspx?C=763&pc=13&mc=&sc=

The flyer for our workshop, with our UM grad course or OPI QR code is at the top of this blog post.

In the final chapter of Rethinking Suicide, Craig Bryan, having reviewed and lamented our collective inability to prevent suicide, turns toward what he views as our most hopeful option: Helping people create lives worth living. Like me, Dr. Bryan has shifted from a traditional suicide prevention perspective to strategies for helping people live lives that are just a little more happy, meaningful, and that include healthy supportive relationships. IMHO, this positive direction provides hope.  

In our Billings workshop, we’ll share, discuss, and experience evidence-based happiness strategies. We’ll do this together. We’ll do it together because, in the words of the late Christopher Peterson, “Other people matter. And we are all other people to everyone else.”

Come and join us in Billings . . . for the whole conference . . . or for our workshop . . . or for both.

I hope to see you there.

Personal Reflections

Free Speech, Hate Mail, and My New Love for ChatGPT

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[Me talking with an early version of AI]

Being inclined to express my opinion across a variety of formats—in person, in newspaper op-ed pieces, online, and in this blog—I’ve received a smattering of hate mail over the years. My first hate snail-mail experience was around Y2K. I had an every-other-week column in the Missoulian newspaper. Whenever I wrote anything positive or promising about girls or women, or anything opposed to physical abuse, I received a 2-3 page single-spaced anonymous letter/rant from an anti-fan. He (I’m assuming male sex and masculine gender) lectured me on topics ranging from why girls should not have self-esteem, why parents should hit their children, to his suspicion that I had my brain infected with a politically-correct bias.

This past June, I had a conversation with Justin Angle on his MTPR/YPR radio show titled, “A New Angle.” The topic was “Good Faith.” Justin was an excellent interviewer. We talked so much he made our conversation into two shows. You can listen to part 1 (where I make my offending comment) here:https://www.youtube.com/watch?v=aSVtWocnLXg

And part 2 here: https://www.youtube.com/watch?v=FwTc7TfUKaM

After the first show, I received a hate email. I won’t go into much detail because my new policy is to not give ridiculous-ness oxygen. Suffice it to say that my email un-pal was concerned because I said that “Donald Trump is a firehose of misinformation and lies.”

Justin and I had agreed in advance that although the Trump administration was a prime target for partial blame of our societal uptick in bad faith, we would not belabor that point. Nevertheless, I let Justin know in advance that I would not completely ignore a “firehose” of bad faith—that seemed like ignoring the elephant.

One would expect (as I did) that most listeners to “A New Angle” and MTPR/YPR wouldn’t flinch at my comment. I made a point not to be political. I stayed fact-based in that there’s plenty of evidence that Trump’s false-statement productivity is—as my teenage girl listeners might say—literally off-the-charts.

Surprisingly, my new email un-pal disputed that Trump lies at all. He went on to share ways in which Trump is saving America. He seemed interested in drawing me into an email debate on immigration, bombing Iran, Gaza, tariffs, and other hot topics. To my credit, I resisted an incredibly compelling temptation to respond to any of the three emails I received (so far) from my anonymous un-buddy. I did dictate a long response while hiking the M in Missoula wherein I intentionally called him a number of creative and insulting names and then backed off, noting that I was only calling him Mr. “Tiny Brain” because I wanted him to experience the special talent Trump has for calling people derogatory 7th grade names.

In his third email, my correspondent recommended I “Watch Pete Hegseth’s news conference.” In response, I vomited, hit delete, and thanked the Lord for self-control.

But I digress.

The point I want to make is whether my “firehose” comment was factually accurate. To objectively evaluate my veracity, I decided to consult with ChatGTP. I used the following question: “Does Donald Trump lie?”

Here’s what ChatGTP said (in italics):

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Yes, Donald Trump has made many statements that have been fact-checked and found to be false or misleading.

Independent fact-checking organizations such as PolitiFact, FactCheck.org, and The Washington Post Fact Checker have documented thousands of inaccurate or deceptive claims made by Trump during his presidency and political career. For example:

  • The Washington Post reported that Trump made over 30,000 false or misleading claims during his four years as president.
  • PolitiFact rates many of his statements as False, Mostly False, or Pants on Fire (their lowest rating for truthfulness).

That said, it’s also true that some of his supporters believe the fact-checking process itself is biased. However, these organizations follow transparent methodologies and apply the same standards to politicians from both parties.

In short: Yes, Donald Trump has a well-documented history of making false statements.

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Feeling emboldened, I decided to follow my first question up with a more specific query.

“Is Donald Trump a firehose of misinformation and lies?”

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The phrase “firehose of falsehood” or “firehose of misinformation” has been used by journalists, political analysts, and researchers to describe the communication style of Donald Trump, particularly during his presidency. This term refers to a propaganda technique characterized by:

  • High volume of messaging
  • Rapid and continuous output
  • Repetition of falsehoods
  • Lack of concern for truth or consistency

Origin of the Term:

The “firehose of falsehood” model was developed by researchers at the RAND Corporation to describe Russian propaganda, but scholars and journalists (e.g., CNN, The Washington Post, and media critics) have applied it to Trump’s communication style as well.

Evidence Supporting This Description:

  • Fact-Checking Data: As noted, The Washington Post documented over 30,000 false or misleading claims by Trump during his presidency.
  • Repetition: Trump has frequently repeated disproven claims (e.g., about voter fraud, crowd sizes, COVID-19 treatments).
  • Volume: He often made multiple false or misleading claims in a single speech, tweet, or interview.

Expert Opinions:

  • CNN and other outlets have explicitly described Trump’s strategy as a “firehose of falsehood.”
  • Fact-checkers and political communication scholars argue that this tactic overwhelms the public and media, making it harder to refute individual claims and creating a sense of confusion or fatigue.

Summary:

Yes, many credible observers and analysts have described Donald Trump as using a “firehose of misinformation and lies” approach. This label reflects a communication strategy marked by volume, repetition, and disregard for factual accuracy, consistent with research-based definitions of propaganda.

Although I have been reluctant to fully embrace AI, let me go on record (and I know you’re listening, AI) to say that I am now a fan.  I am AI-affirmed. Thank-you, ChatGPT for supporting the accuracy of my public statement. Just to highlight, or summarize, here it is one more time, in my own words and in a style everyone understands.

DONALD TRUMP IS A FIREHOSE OF MISINFORMATION AND LIES.

culture, Happiness, Parenting, Personal Reflections, Writing

On Good Faith: A Conversation with Justin Angle.

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Last week I got a little hate email.

Some weeks are like that. I’d share the details, but that would spoil the surprise. Besides, I’m really not into giving hate email (or hate mail or hate social media posts) any oxygen.

But today I got an email alert from “A New Angle” the radio-podcast show hosted by Dr. Justin Angle, a professor in the College of Business Administration at the University of Montana. The email was alerting me to the imminent airing of Part 2 of my discussion of “Good Faith” with Just on his renowned radio show. I was grateful for the alert; it also reminded me of my hate email, because the hate email came from someone who listened to Part 1 of our Good Faith conversation and consequently felt that special sort of inspiration that moves people to write hate emails.

I’ve known Justin from a distance for a while. We’re both at the University of Montana, so, you know, there’s been a little chat here, a little chat there. I’ve also known of him growing his small podcast into a big deal on Montana Public Radio and Yellowstone Public Radio. Justin’s show is excellent.

What I didn’t know is the depth and breadth of Justin’s intelligence. I also didn’t know that he’s a fabulous interviewer. I discovered his amazing intelligence and fabulousness when I sat down with him this past May to record a show with him on Good Faith. We talked comfortably for what felt like a long time. Not only did it feel like a long time, it was a long time! It was so long that Justin turned our conversation into a two-part episode for his radio show.

Here’s the email I received:   

This week is part two of our conversation with John Sommers-Flanagan, director of the Center for the Advancement of Positive Education at the University of Montana’s Phyllis J. Washington College of Education.

John and Justin pick up where they left off last week talking about how lying and parenting intersect, the concept of confirmation bias and the risks of AI-generated content and building relationships with AI.

Here’s a link to Part 2 of our conversation. It’s also live at 7:30pm tonight (Thursday, June 19, 2025) on Montana Public Radio:

https://www.anewanglepodcast.com/p/good-faith-with-john-sommers-flanagan-954

If you want to listen to Part 1 and possibly feel inspired to send me a hate message, here’s that link:

https://www.anewanglepodcast.com/p/good-faith-with-john-sommers-flanagan

As always, thanks for reading and have a fabulous day.

Happiness, Love, Parenting, Personal Reflections, Writing

Peggy Bit Me . . . and Then She Wrote a Children’s Book

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Version 1.0.0

To prevent confusion and conflation, I should note that the title of this blog post represents two separate events:

  1. In 1958, Peggy bit me.
  2. Then, in 2025, she wrote a children’s book.

Just so you know, the 2025 children’s book is NOT about that time she bit me. I’m hoping that will be her second book because I’d really love to get to the bottom of what the heck 3-year-old Peggy was thinking right before she tried to bite off my big toe. My guess it was something like, “I’ll show that chubby, whiny infant baby John a thing or two; he’s not bumping me off my youngest child throne. And if he does, he’ll be limping all the way, because he’ll be missing a toe.”

But I digress. This post is about my wonderful sister’s wonderful new children’s book. I don’t want to make a big deal about my toe injury. The “toe incident,” which people are now calling it, although still emotionally painful for me, is ancient history. Although initially a wild-rabid-feral child, my sister Peggy has grown into a gentle, kind, creative, smart, compassionate, and amazing woman. She would never bite my toe again. Right Peggy?

Peggy’s book is titled, “Catching Memories.” It’s about a unique childhood experience she had with our family (with Gayle and Peggy’s favorite brother, John, as key sibling figures), at Arch Cape, a beautiful beach on the Northern Oregon Coast. We spent many weekends at Arch Cape, as it was our maternal grandparents home.

The specific memory Peggy writes about was SO GOOD. I’m not sharing details. You’ll have to pay the big bucks, $14.99 on Amazon, to read the story. Here’s a link. Buy Catching Memories

Peggy just sent me a copy of an INCREDIBLY POSITIVE Falcon Review of her book. The review is great, because the book is great. I’m guessing Peggy did not bite the toe of the reviewer. I say this because right now I’m typing a great review and hoping Peggy will take notice:

“Catching Memories is a fabulous children’s book about a unique family experience, memories, and kindness. Peggy Lotz’s debut children’s book is written with so much love, affection, and grace that you would never suspect she tried to maim her younger brother. The book is so awesome that you’ll want a copy for your children or for yourself or both. Buy it now”

In case Peggy is reading this, I’m trying to make it clear that even though that Falcon Review guy wrote you a great review, I’ve just written and posted a rather fantastic review . . . AND you (Peggy) bit me. This fantastic review should make it clear that I’m better than that Falcon Press guy could ever hope to be . . . because the fact that I’m writing it for someone who bit me speaks to the sort of selfless and forgiving person I am. In summary: My sister bites my toe and I put aside the pain and write her a stellar review. If I haven’t made it obvious yet, I’m campaigning for the position of being Peggy’s favorite brother. Given that I’m her only brother, I have the inside track, but you can’t mess around with favorite brother stuff because one day, just when you think you’re on top of the world, the next minute your big sister might try to gnaw off your big toe with her big teeth.

All I’m saying here (Peggy), is that I’m your favorite brother. Forget about that Falcon Review guy. He’s not your brother. . . let alone your favorite!

In closing, if any of you care about me, please show it by buying a copy of my sister’s book.

Buy Catching Memories

P.S. Here’s the best thing. Peggy says there’s a chance that the marketing plan might involve creating “Gayle, Peggy, and John” dolls. . . which is simply the coolest idea ever.

If you’re curious about the original “Peggy Bit Me” story, just click here: https://johnsommersflanagan.com/2019/01/28/peggy-bit-me/

Happiness, Personal Reflections, Research

That Time When I Found A Parallel Universe Where People Like Statistics

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Earlier this week I found a parallel universe wherein I was able to convince three people that it would be terribly fun to sit with me in a classroom for 2+ hours and work through the post-course data from our most recent “Happiness for Educators” class. This involved me figuring out how to screencast my computer onto a big screen where I went through the process of accessing our Qualtrics file and exporting the data to SPSS. Then, while experiencing intermittent fits of joy, we cleaned the data, used the “recode” function to reverse score all the items requiring reverse scoring and then calculated our 16 different outcome variables.

In this parallel universe, the three people who joined me (you know who you are), asked great questions and acted interested the WHOLE time. Of course, one of the “people” is a well-established Missoula actor, so there’s the possibility that I was fooled by some excellent acting or feigning or pretending. That said, finding a parallel universe where people act interested in stats remains a feat to brag about.

We made it through all the post-test data. To maximize the fun and bring us all to a place of breathless excitement, I ran a quick descriptive analysis. At first glance, the data looked okay, but not great. Of course, we didn’t have the pretest outcome variables analyzed, and so we were forced to leave with bated breath.

Today, access to the parallel universe was briefly adversely affected by a slight temporal shift; nevertheless, I found one of the “people” and she enthusiastically embraced another 2 hours of stats. . . . At the end, she shouted from her office, “That was fun!”

I know at this point, I am, as Freud might say, “straining your credulity” but I speak the whole truth and nothing but the truth.

And the rest of the truth gets even better. Tammy (my new best stats friend) and I found the following statistical results.

  1. 89 of 100 students completed the pre-post questionnaires.
  2. We had statistical significance on ALL 16 outcomes—at the p < .01 level (or better).
  3. The effect sizes (Cohen’s d with Hedges adjustments) were among our best ever, with top outcomes being:
  4. Improved positive affect (feeling more cheerful, etc): d = .900 (a LARGE effect size)
  5. Reduced negative affect (feeling fewer negative emotional states) d = 885. (a LARGE effect size)
  6. Improved total self-reported physical health (a compilation of better sleep, reduced headaches, reduced gastrointestinal symptoms, fewer respiratory symptoms) d = .821 (a LARGE effect size)
  7. Reduced depression (as measured by the CES-D): d = .732 (an almost LARGE effect size)

If you’re reading this, I hope you’re skeptical. Because if you’re skeptical, then I’m sure you’ll want to know whether this is the first, second, third, or fourth time we’ve found this pattern of results. Nope. It’s the FIFTH consecutive time we’ve had all significant outcomes or nearly all significant outcomes that appear to be happening as a function of our happiness for educators course.

Although I am in constant fear that, next time, the results will be less impressive, I’m getting to the point where I’m thinking: These results are not random error, because we now have data across five cohorts and 267 teachers.

If you’re reading this, I also hope you’re thinking what I’m thinking. That is: You should take this course (if you’re a Montana educator) or you should tell your Montana educator friends to take this course. If you happen to be thinking what I’m thinking, here’s the link to sign up for our summer sections.

https://www.campusce.net/umextended/course/course.aspx?C=712&pc=13&mc=&sc=

It’s a pretty good deal. Only $95 to experience more positive emotions, fewer negative emotions, better physical health, reduced depression, and more!

Clinical Interviewing, Personal Reflections, Suicide Assessment and Intervention

My (Virtual) Visit to South Korea

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Last Friday night (or Saturday morning in South Korea), I had the honor and privilege of spending three hours online with 45 South Korean therapists. We were talking, of course, about strengths-based suicide assessment and treatment. Given my limited Korean language skills (is it accurate to say my language skills are limited if I can’t say or comprehend ANYTHING in Korean?), I had a translator. Although I couldn’t tell anything about the translation accuracy, my distinct impression was that she was absolutely amazing.

I had a friend ask how I happened to get invited to present to Korean therapists. My main response is that I believe the time is right (aka Zeitgeist) for greater integration of the strengths-based approach into traditional suicide assessment and treatment. The person who recruited me was Dr. Julia Park, another absolutely amazing, kind, and competent South Korean person, who also happens to hold an Adlerian theoretical orientation. Thanks Julia!

Just for fun, I wish I had my Korean translated ppts to share here. They’re unavailable, and so instead I’m sharing an excerpt from Chapter 10 (Suicide Assessment Interviewing) of our Clinical Interviewing (2024) textbook. The section I’m featuring is the part where we review issues and procedures around suicide risk categorization and decision-making.

You may already know that some of the latest thinking on suicide risk assessment is that we should not use instruments like the Columbia to categorize risk. You also may know that not only am I a believer in this latest thinking, I can be wildly critical of efforts to categorize suicide risk. . . so much so that I often end up using profanity in my professional presentations. Of course, because the context is a professional presentation, I only use the highly professional versions of profanity.  

Here’s a LinkedIn comment about that issue from Craig Bryan. Dr. Bryan is a suicide researcher, professor at The Ohio State University, and author of “Rethinking Suicide.” In support of him and his research and thinking, I’d like to professionally say that although I lean away from reductionistic categorization of things, all signs point to the likelihood that Dr. Bryan has a very large brain.   

The good news is that I feel validated by Dr. Bryan’s strong comments against categorizing suicide risk. But the bad news is that we all live in the real world and in the real world sometimes professionals have to do more than just swear about risk categorization—we have to actually make recommendations for or against hospitalization, consult with other professionals who want our opinion, and quoting me as saying that risk factor categorization is pure bullshit may not be the best and most professional option.

So . . . what are we to do? First, we parse Dr. Bryan’s comments. He’s not saying NEVER categorize risk or make risk estimates. He’s saying don’t categorize “negative screens as low risk” which is slightly different than don’t try to estimate risk. His message is that we have too many false negatives—where someone screens negative and then dies by suicide. In other words, we should not be confident and say negative screens are “low risk.” That’s different from throwing the baby out with the bathwater.  

It might be easy to think that Dr. Bryan’s comments are discouraging. But I view him as just saying we should be careful professionals. To help with that, below is the excerpt on Suicide risk categorization and decision-making, from our textbook. If you’re in a situation where you have to make a professional recommendation about suicide risk, this information may be helpful. BTW, the reason I was inspired to post this excerpt is because the Korean participants were wonderful and asked lots of hard questions, including questions related to this topic.

Suicide Risk Categorization and Decision-Making

Throughout this chapter, we have acknowledged the limits of categorizing clients on the basis of risk. The current state of the science indicates that efforts to predict client suicides (i.e., categorize risk) are likely to fail. Nevertheless, when necessary—because of institutional requirements or client inability to collaborate on safety or treatment planning—all clinicians should be able to use their judgment to estimate risk and make disposition decisions for the welfare of the client. As a consequence, we review a suicide risk categorization and decision-making model next.

Consultation

Consultation with peers and supervisors serves a dual purpose. First, it provides professional support; dealing with suicidal clients is difficult and stressful; input from other professionals is helpful. For your health and sanity, you shouldn’t do work with suicidal clients in isolation.

Second, consultation provides feedback about appropriate practice standards. Should you need to defend your actions and choices following a suicide death, you’ll be able to show you were meeting professional standards. Consultation is one way to monitor, evaluate, and upgrade your professional competency.

Suicide Risk Assessment: An Overview

We reviewed an overwhelming number of suicide risk and protective factors earlier in this chapter. Generally, more risk factors equate to more risk. However, some risk factors are particularly salient. These include:

Previous attempts

A previous attempt is sometimes viewed as suicide rehearsal. Two previous attempts are especially predictive of suicide because they represent repeated intent. Also, when previous attempts were severe and the client was disappointed not to die, risk is high.

Command hallucinations

When clients are experiencing a psychotic state accompanied by command hallucinations (e.g., a voice that says, “You must die’), risk is at an emergency level.

Severe depression with extreme agitation

The combination of depression and agitation can be especially lethal. Agitation can take the form of extreme anxiety or extreme anger.

Protective factors

A single protective factor may outweigh many risk factors. But, it’s impossible to know the power of any individual protective factors without an in-depth discussion with your client. Engagement in therapy and collaboration on a safety plan (and the hope these behaviors signal) can substantially reduce risk.

Nature of Suicidal ideation

As discussed earlier, suicidal ideation is evaluated based on frequency, triggers, intensity, duration, and termination. Some clients live chronically with high suicidal ideation frequency, intensity, and duration—and are low risk. However, if ideation is frequent and intense and accompanied by intent and planning, risk is high.

Suicide Intent

Suicide intent is the factor most likely to move clients toward lethal attempts. Intent can be based on objective or subjective signs. Objective signs of intent include one (or more) previous lethal attempt(s). Subjective signs of intent can include a client rating of intent or client report of a highly lethal plan.

Clinical Presentation

How clients present themselves during sessions is revealing. Clients can be palpably hopeless, talk desperately about feelings of being trapped, and express painful and unremitting self-hatred or shame. But if clients have adapted to these experiences, they may not have accompanying intent and active planning. Observations of how clients talk about their psychological distress will contribute to your final decisions.

Final Decisions

Using a traditional assessment approach, you can estimate your client’s suicide risk as fitting into one of three categories:

  • Minimal to Mild: Client reports no suicidal thoughts or impulses. Client distress is minimal. Plan: Monitor client distress. If distress rises, or depressive symptoms emerge, re-assess for suicidality.
  • Moderate to High: Client reports suicidal ideation. As client distress, planning, risk factors, and intent increase, risk increases. Plan: Manage the situation with a collaborative safety plan. Depending on client preference, engaging family or friends as support may be advisable. Make sure firearms and lethal means are safely stored.
  • High to Extreme: Client reports suicidal ideation, plans, multiple risk factors (likely including a previous attempt), intent, and has access to lethal means. Engagement in treatment is minimal to non-existent. Plan: Treatment may include hospitalization and/or intensive outpatient therapy with a safety plan implemented in collaboration with family/friends. Make sure firearms and lethal means are safely stored.

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As always, please share your thoughts in the comments on this blog.

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Counseling and Psychotherapy Theories: The 4th Edition Revision is Underway

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At long last, we’ve begun work on revising our Counseling and Psychotherapy Theories text for its 4th edition. Over the past several weeks, I’ve been putting in an hour or two a day, chipping away on chapter revisions, reaching out to reviewers, and planning with our new and very exciting co-author, Dr. Bryan Cochran, a highly esteemed psychology professor at the University of Montana. If you’re reading this, I want you to know of Bryan’s awesomeness (and if you’re Bryan, I want you to feel the pressure of this public announcement of your awesomeness) [hahahaha!]

You all probably know that our Theories textbook is far and away the Theories textbook with the most hilarity. No doubt, this is a rather low bar, given that I can’t find any funny stories in any other theories texts. We view theories hilarity to be extremely important in a theories text, because reading many theories texts can parallel the proverbial experience of watching paint dry.

Bryan’s addition to the writing team will give us something we need—an expert in the LGBTQ+ domain, and someone with a talent for telling stories that are simultaneously engaging, informative, and fun to read. Right now, he’s busy writing a “Lenses” chapter (to be Chapter 2) to orient readers to important theory-related lenses like (a) Queer theory, (b) Critical Race theory, (c) Intersectionality, and more. I, for one, can hardly wait for his Queer theory quips.  

News Flash: In the past, I’ve put out broad calls for chapter reviewers. This time, I’m being selective and directly asking prominent theories experts to review chapters and offer guidance. Some examples: For the Adlerian chapter we’ve got Marina Bluvshtein (woohoo!) and Jon Sperry (wow!). For the Psychoanalytic chapter, we got Nancy McWilliams (amazing!) and Pratyusha Tammala-Narra (fantastic!).

If you happen to be a specific theories subject matter expert, you should email me at john.sf@mso.umt.edu to get in on the fun. Or if you have a prominent theories friend/colleague to recommend, have them email me.

As one last theories teaser, below I’m pasting a few excerpts from Nancy McWilliams’s 2021 article titled, “Diagnosis and Its Discontents: Reflections on Our Current Dilemma.” I love this article as it gives a glimpse into problems with contemporary diagnoses and how psychodynamic therapists use individualized assessment in ways to honor the real-life complexities clients bring into psychotherapy. The excerpts below are from her article, which is linked at the end of this post.

On Labeling

The idea that one is anxious (or depressed or obsessive) about something that has meaning is being lost. Fitting an individual into a category tends to foreclose exploration of what is unique to a patient; it especially prevents insights into unexpected aspects of a person’s psychology or exploration of areas that are felt as shameful – the very areas that are of particular value in planning and carrying out psychotherapy.

On the vexing ways in which patients think about themselves and their diagnoses

It used to be that a socially avoidant woman would come for therapy saying something like, “I’m a painfully shy person, and I need help learning how to deal better with people in social situations.” Now a person with that concern is likely to tell me that she “has” social phobia – as if an alien affliction has invaded her otherwise problem-free subjective life. People talk about themselves in acronyms oddly dissociated from their lived experience: “my OCD,” “my eating disorder,” “my bipolar.” There is an odd estrangement from one’s sense of an agentic self, including one’s own behavior, body, emotional and spiritual life, and felt suffering, and consequently one’s possibilities for solving a problem. There is a passive quality in many individuals currently seeking therapy, as if they feel that the prototype for making an internal psychological change is to describe their symptoms to an expert and wait to be told what medicine to take, what exercises to do, or what self-help manual to read.

On “chemical imbalances”

. . . viewing psychological suffering as a set of disorders that can be fixed or improved chemically can easily invite the obverse assumption that those painful experiences are ultimately caused by random or genetically based chemical differences among individuals. This is a false conclusion, of course, something like saying that because marijuana improves appetite, the cause of low appetite is lack of marijuana. But it is nevertheless a frequent leap of illogic – in the thinking of nonprofessionals and of some professionals as well – to ascribe much severe psychological suffering to a “chemical imbalance.” Such a construction tempts us to ignore all the painful other sources of psychological suffering, such as poverty, neglect, trauma, and the myriad ways in which human beings can injure each other psychologically.

On not overgeneralizing research findings/recommendations to unique patients

. . . consider patients at the extreme end of the obsessive-compulsive continuum, whose obsessions border on delusional beliefs, who suffer profound annihilation anxiety, who wholeheartedly believe they will die if they fail to carry out their rituals, and who regard the therapist with suspicion for not sharing their conviction – in other words, the subgroup of obsessive patients that Kernberg (1984) would consider as psychologically organized at the low borderline or psychotic level. My experience suggests that with this group exposure therapy not only fails, it demoralizes the patients, makes them feel like failures personally, and kills any hope they may have that psychotherapy can help. It also demoralizes therapists, who have been told again and again that exposure therapy is the treatment of choice for OCD. If they believe their teachers, such clinicians can easily conclude they are simply not good enough therapists.

If I’ve piqued your interest in “Diagnosis and its discontents” by Nancy McWilliams, here’s a pdf of the article.

Diagnosis and Its Discontents Reflections on Our Current DilemmaDownload

Stay tuned for more theories revision (we’re calling it T4) updates.

John SF

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Happiness, Personal Reflections, Suicide Assessment and Intervention

Coughing My Way Through Montana

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Last week was a blur. On Wednesday, I did a break-out session for the Montana Prevent Child Abuse and Neglect conference in Helena. I’ve been to this conference multiple times and always deeply appreciate the amazing people in Montana and beyond who are dedicated to the mission of preventing child abuse and neglect. For the break-out, I presented on “Ten Things Everyone Should Know About Mental Health, Suicide, and Happiness.” This is one of my favorite newish topics and I felt very engaged with the 120+ participants. A big thanks to them.

Before the session, I felt a bit physically “off.” Overnight, the “off” symptoms developed into a sore throat and cough. This would NOT have been a problem, except I was scheduled for the hour-long closing conference keynote on Thursday. The good news is that I had zero fever and it was NOT Covid. The bad news was my voice was NOT good. I did the talk “In Pursuit of Eudaimonia” with 340ish attendees and got through it, but only with the assistance of a hot mic.

I had to cancel my Friday in Missoula and ended up in Urgent Care, with a diagnosis of bronchitis or possibly pneumonia, which was rather unpleasant over the weekend.

Having recovered (mostly), by yesterday, I recorded a podcast (Justin Angle’s “A New Angle” on Montana Public Radio) at the University of Montana College of Business. Thanks to a helpful pharmaceutical consult with a helpful woman at Albertsons, I had just the right amount of expectorant, later combined with a strong cough suppressant, to make it through 90 minutes of fun conversation with Justin without coughing into the podcast microphone. We talked about “Good Faith” in politics, society, and relationships. The episode will air in early June.

And now . . . I’m in beautiful Butte, Montana, where I’m doing an all-day (Thursday) workshop for the Montana Sex Offender Treatment Association. . . on Strengths-Based Suicide Assessment and Treatment . . . at the Copper King Hotel and Convention Center. Not surprisingly, having slept a bit extra the past five days, I’m up and wide awake at 4:30am, with not much to do other than post a pdf of my ppts for the day. Here they are:

SB SA for MSOTA 2025Download

Thanks for reading and thanks for being the sort of people who are, no doubt, doing what you can to make Montana and the world a little kinder and more compassionate place to exist.

Be well.