Early this morning, I had a chance to Zoom in and present a workshop for Saint Michael’s College in Vermont. This was probably a good thing, because they had more than their share of snow to deal with. I got to be in Vermont virtually from beautiful Missoula Montana, where we’ve had spring most of winter. I wish we could borrow a few feet of that Vermont snow to get us up to something close to normal.
But my point is to share my ppts from this morning, and not talk about the weather. I had a great two hours with the Saint Michael’s professionals . . . as they posed excellent and nuanced questions and made insightful comments. Here’s a link to the ppts:
While I blog away, WordPress counts things. I don’t exactly understand how it works, but apparently my little blog just passed the 1.0 million visitor and 1.5 million views thresholds. Wow.
You may be wondering, what does passing that million-visitor pinnacle mean, and why is JSF sharing about his blogging achievements?
The answer to that important question is: All this means it’s time to celebrate!
In honor of this blogging achievement, I’m doing what bloggers are supposed to do. I’m honoring my million visitors by giving out five free books.
To “win” a book, all you have to do is post here, a nice, supportive, celebratory comment of at least 20 words about this blog. If you’re one of the first five to post a comment in response to this historic blog celebration, you should also email me your best mailing address. Then, if you’re quick at the blog commenting draw, in the next couple weeks, you will receive one shiny new copy of the exciting thriller titled, “Suicide Assessment and Treatment Planning: A Strengths-Based Approach” by John and Rita Sommers-Flanagan.
Thanks for following and reading my blog. Today’s news means, quite literally, that “You are one in a million!”
I very much appreciate your support. I hope you’ve enjoyed, or appreciated, or at least not hated my idiosyncratic and sometimes irreverent posts.
Yesterday I had a chance to do a 3-hour online workshop with a very cool group of about 22 smart, skilled, and dedicated professionals. They engaged with the content and consequently, we had some great discussions. One of the discussions has kept percolating for me today. The topic: How do we handle situations where clients are clearly suicidal, but are reluctant or unwilling to develop and agree to a collaborative safety plan.
We talked about how, often, the knee-jerk impulse is to pursue hospitalization. While that’s a viable and reasonable option, the problem is that hospitalization and discharge is a notable risk factor for death by suicide. The other problem is that it’s pretty much impossible for us to know if the client’s resistance to a safety plan indicates increased risk, or just resistance to what s/he/they view as a coercive mandate.
There’s no perfect clinician response to this dilemma. Hospitalization helps some clients, and causes demoralization and regression in others. Not hospitalizing can feel too risky for practitioners.
We talked about a few guidelines in dealing with this conundrum. They include: (a) consulting with colleagues, (b) reflecting on the client’s engagement in other aspects of treatment (increased engagement in treatment is a protective factor), (c) evaluating client intent and client impulsivity, and (d) documenting your decision-making process (including citations indicating that psychiatric hospitalization may not be the best alternative). But again, there’s no perfect guideline.
When discussing Kate’s situation and other scenarios that involve outpatient work with highly suicidal clients, the following question usually comes up, “What if your judgment is wrong and she either makes a suicide attempt, or she kills herself before your next session?” This is a great question and gets to the core of practitioner anxiety.
The answer is that, yes, she could kill herself, and if she does, I’ll feel terrible about my clinical judgment. Also, I might get sued. And, if I’m inclined toward suicidal thoughts myself, Kate killing herself might precipitate a suicidal crisis in me. Sometimes suicide tragedies happen, and sometimes we will feel like the tragedy was our fault and that we should have or could have prevented it. That said, most suicides are more or less unpredictable. Even if you think you’re correct in categorizing someone as high or low risk, chances are you’ll be wrong; many high-risk clients don’t die by suicide and some low-risk clients do (see Sommers-Flanagan, 2021, for a personal essay on coping with the death of a client to suicide; https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility).
More depressing is the reality that hospitalization – the main therapeutic option we turn to when clients are highly suicidal – isn’t very effective at treating suicidality and preventing suicide (Large & Kapur, 2018). Hospitalization sometimes causes clients to regress and destabilize, and suicide risk is often higher after hospitalization (Kessler et al., 2020). Because hospitalization isn’t a good fit for many clients who are suicidal and because we can’t predict suicide very well anyway, some cutting edge suicide researchers recommend intensive safety planning as a viable (and often preferred) alternative to hospitalization. In the case of Kate, as long as she’s willing to collaborate, and I’m able to contact her husband, and we can construct a plan that provides safety, then I’m on solid professional ground (or at least as solid as professional ground gets when working with highly suicidal clients).
Kessler, R. C., Bossarte, R. M., Luedtke, A., Zaslavsky, A. M., & Zubizarreta, J. R. (2020). Suicide prediction models: A critical review of recent research with recommendations for the way forward. Molecular Psychiatry, 25(1), 168-179. doi:http://dx.doi.org/10.1038/s41380-019-0531-0
Large, M. M., & Kapur, N. (2018). Psychiatric hospitalisation and the risk of suicide. The British Journal of Psychiatry, 212(5), 269-273.
The idea that healthcare professionals must take an authoritarian role when evaluating and treating suicidal clients has proven problematic (Konrad & Jobes, 2011). Authoritarian clinicians can activate oppositional or resistant behaviors (Miller & Rollnick, 2013). If you try arguing clients out of suicidal thoughts and impulses, they may shut down and become less open.
For decades, no-suicide contracts were a standard practice for suicide prevention and intervention (Drye et al., 1973). These contracts consisted of signed statements such as: “I promise not to commit suicide between my medical appointments.” In a fascinating turn of events, during the 1990s, no-suicide contracts came under fire as (a) coercive and (b) as focusing more on practitioner liability than client well-being (Edwards & Sachmann, 2010; Rudd et al., 2006). Suicide experts no longer advocate using no-suicide contracts.
Instead, collaborative approaches to working with suicidal clients are strongly recommended. One such approach is the collaborative assessment and management of suicide (CAMS; Jobes, 2016). CAMS emphasizes suicide assessment and intervention as a humane encounter honoring clients as experts regarding their suicidal thoughts, feelings, and situation. Jobes and colleagues (2007) wrote:
CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts.” (p. 285)
Tomorrow I’ll be presenting all day on Strengths-Based Suicide Assessment and Treatment at Water’s Edge Counseling Services in Rogers, Arkansas. Water’s Edge Counseling Services employs dozens of therapists at four locations. They continue to grow to meet the mental health needs of Arkansas residents. You can find information about their services here: https://www.watersedgecounselingnwa.com/
In anticipation of tomorrow, I looked up some stats on suicide in Arkansas and the U.S.
In the U.S. – the average rate of death by suicide (from 2022) is 14.5 per 100,000
New Jersey had the lowest 2022 rates at 7.6.
Wyoming had the highest at 31.8.
Arkansas was at 19.5.
Montana was at 27.5.
Today has been a hard day in Montana, as I’ve heard about two deaths by suicide by individuals in the social world of friends and family. Suicides are tragic and difficult to understand. When suicide happens, it’s important to remember many things, but a couple key points come to mind today.
It’s estimated that each suicide affects about 150 people. If you’re feeling guilty and like you should have or perhaps could have done something to save a life, you’re likely not alone.
Although you’ll often see messages in suicide prevention presentations or on the internet that suicide is 100% preventable, that’s not really true. In fact, we do more prevention now than ever before in the history of time and the U.S. rates have steadily risen over the past 25 years, in the face of all our prevention efforts.
My big points are that suicide is very difficult to predict and prevent and yet it’s very easy and common for people to feel guilty when someone they know dies of suicide . . . even though the people left behind are not at fault.
However your day has gone today, I wish you as much peace and comfort as possible. If you’re feeling suicidal or especially guilty, please reach out to someone who loves you. They will be happy to talk. Or, if you feel the need, you can call the national suicide crisis hotline: 988. Or, if you’re a texter, there’s a text hotline. Just text HOME to 741741 to connect with a volunteer Crisis Counselor.
All my best to you . . . and here are the ppts for tomorrow’s presentation:
In the piece I review some information and make one point that I’d like to share more broadly. Below are several opening paragraphs from the Op-Ed piece.
*Beginning of Excerpt*
Beyond Suicide Prevention: The Montana Happiness Challenge
John Sommers-Flanagan, Ph.D.
All September, organizations and individuals celebrated suicide prevention month, sharing information about suicide and promoting strategies for preventing suicide deaths. Although the information was life-affirming, underneath the messaging lies an unpleasant truth: Broadly speaking, suicide prevention has been failing for over two decades.
In August, the Centers for Disease Control (CDC) released provisional United States suicide data for 2022. The news was bad. An estimated 49,449 Americans died by suicide in 2022—the highest number ever recorded in U.S. history.
The bad news goes far beyond last year. Suicide rates have risen every year for over 20 years, with only two puzzling exceptions. In 2020 and 2021—during the onset of COVID-19, lockdowns, and other national stressors—suicide rates declined; they declined despite the fact that by every other measure Americans were suffering from unprecedented stress, depression, anxiety, and suicidal thinking. Suicide researchers have long noted this odd pattern: higher stress, depression, anxiety, and suicidal thinking do not inevitably translate to more suicides.
If all this seems confusing—20 years of vigorous suicide prevention, and suicide rates steadily rise, while during 2 years of intensive COVID-related individual and public distress, suicide rates go down—it’s only because it is.
In his book, Rethinking suicide, Craig Bryan, a renowned suicide researcher, called suicide “a wicked problem,” noting, “Wicked problems cannot be definitively solved or completely eliminated . . .” In fact, as Bryan and others have described, efforts to eliminate wicked problems sometimes make them worse. The preceding facts don’t indicate suicide prevention doesn’t work . . . and they don’t mean COVID pandemics solve the suicide problem. What they do mean—at minimum—is that suicide prevention doesn’t work for everyone, and we need to collectively think differently about this wicked problem.
Suicide prevention ideology over-focuses on eliminating “bad” or negative thinking and behavior. This conceptualization is contrary to science and common sense. The science says that telling people to stop engaging in unhealthy behaviors usually doesn’t work. When people are judged and told they should change, they often become defensive and more resistant to change. This is human nature.
All this brings me to share one strategy for moving beyond traditional suicide prevention. We should put more energy into growing and nurturing positive and meaningful thoughts and behaviors. People are more likely to change if they’re accepted for who they are, and then invited to try something interesting.
*End of Excerpt*
If you read the preceding and have a reaction, I’d love to hear your thoughts on how, with increasing suicide prevention focus, the suicide deaths keep increasing, and why, during the two worst years of COVID, suicide deaths decreased. Feel free to post on this blog or pop me an email.
This week, for the Montana Happiness Challenge, we’re focusing on adopting a mindset where we look for joy or for what inspires us. Last week I did a day-long training on Suicide Assessment and Treatment with professionals in Canada. At the end of the day, I was inspired that they took a full-day to learn about something so hard and challenging. Similarly, if you got through this whole blog because of your interest in making the world a better place, you inspire me.
If you want to keep up with the Montana Happiness Challenge, here are some clickable options:
Last week I did a little cliff-jumping into the Stillwater River with my twin 13-year-old grandchildren. It was only about 20 feet, but high enough to feel the terror and exhilaration of a brief free-fall.
This week I’m having a different kind of buzz. Dr. Margaret Rutherford reached out to me with a link to her TEDx Boca Raton talk. Previously I was a guest on her video podcast show (here’s the link to her podcast page: https://drmargaretrutherford.com/podcast-2-2/, and a link to her website and book, “Perfectly Hidden Depression” https://drmargaretrutherford.com/perfectlyhiddendepressionbook/). We’ve stayed in touch via email. Along with her link, she apologetically noted that she “barely” got a plug in for my work on strengths-based suicide assessment. I thought it was incredibly nice for her to give a nod, even a brief one, to my work. But then I watched and discovered that she had only mentioned three professionals: Edwin Shneidman (the “Father of Suicidology), Sidney Blatt (a renowned suicide and depression researcher from Yale), and some obscure guy from the University of Montana (that would be me).
Aside from feeling honored, humbled, and flattered to even get a mention, Dr. Margaret’s talk is fantastic. She makes the point–with a couple of articulate cases–for moving away from a strictly medical model perspective and toward working with people who may be suicidal through a lens of no judgment and acceptance. Here’s the link to her talk, which is well-worth a watch: https://www.youtube.com/watch?v=lXZ5Bo5lafA
There are other signs that how professionals (and hopefully the public) view suicidal ideation and behavior may be shifting toward greater acceptance. I’ll go into these other signs in a future post, but right now I want to emphasize that the point is not to replace the medical model, but to move the needle toward less pathologizing and more acceptance of the fact that having suicidal thoughts is often a normal part of life. To the extent that we can approach people who are thinking about suicide with, as Dr. Margaret said, “non-judgment and acceptance,” the more likely they are to be open with us about their pain. . . and . . . when people are open about their pain and suffering, then we have a chance to listen with empathy and a greater opportunity to be of help. . . which, I think, is the main point.
I just finished a nice session on the strengths-based approach to suicide with the NDCA. They asked for a little extra info/emphasis on working with men, because men are particularly vulnerable to suicide, and so I wove in some of the content from my ACA presentation with Matt Englar-Carlson and Dan Salois (thanks Matt and Dan!).
The ppt below is a big one because it includes an embedded video featuring a young man who articulates a number of potential suicide related drivers, including trauma (be forewarned: the content is intense and potentially triggering).
A big thanks to the NDCA organizers and to the attendees who were very impressive.
This morning I’m doing a one-hour webinar for Division 17 of the American Counseling Association. The focus is on how we can do suicide assessment, treatment, and prevention with people from historically and currently marginalized or oppressed communities. To deal with this immense issue, it would help if we had some superpowers.
We know, from decades of sociological and psychological research that many different factors contribute to global and regional changes in suicide rates. We also know that, in general, suicide is at least in part driven by individual experiences and perceptions of high personal distress (Shneidman’s “psychache”). Researchers have also identified how poverty, racism, and factors like neighborhood safety/climate can contribute to suicidality. In our suicide book, we call these factors–factors that are typically outside of the self, but that can be internalized–as “contextual.” What follows is an excerpt on contextual factors from Suicide Assessment and Treatment Planning: A Strengths-Based Approach.
Externalizing the External
At age 82, in an interview with the Los Angeles Times (Stein, 1986), B. F. Skinner said: “I have to tell people that they are not responsible for their behavior. They’re not creating it; they’re not initiating anything. It’s all found somewhere else.”
We find Skinner’s words reassuring. All humans are influenced—to some extent—by factors outside themselves. This is not to say people are helpless victims of their environments; there are methods for coping with external stressors. But the first step, even though the stressor is obviously external, is to re-externalize it, because all too often, it’s all too easy, to internalize the external.
Coping Strategies for Toxic or Malignant Stressors
When clients are exposed to larger sociological and uncontrollable stressors, they can experience frustration, helplessness, and hopelessness. As a counselor, mostly you’re unable to change the unchangeable for your clients. Within the counseling relationship, you can express both empathy for your client’s situation, and indignation that society can be so painful and difficult to change. Depending on the counseling goals, you can provide empathy, commiseration, assistance in discerning achievable goals, learning opportunities, and advocacy or support for activism.
Empathic Commiseration
News events pertaining to racism, climate change, global pandemics, and other topics activate and agitate some clients (and counselors). When this happens, empathic commiseration is a good first step. Empathy from you can universalize client emotional reactions and help clients feel more normal. Simple statements like, “I agree. It’s so hard to watch the news” can facilitate recognition that excessive media exposure heightens feelings of helplessness and depression.
Other scenarios where clients are exposed to environmental toxicity, but unable to extricate themselves from the situation, can be especially demoralizing. In such cases, brainstorming about how to mobilize community resources, how to gain access to safe spaces, and how to engage in self-advocacy can be important and empowering. As with goal-setting in other dimensions, helping clients evaluate their own behaviors and the factors over which they have control, may mitigate frustration. Having you to resonate with their frustration and show compassion is crucial.
Discernment and Goal-Setting
People associated with Alcoholics Anonymous are familiar with Richard Neibauer’s (1932) serenity prayer: God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference. Similar guidance comes from Shantideva, an 8th century Indian Buddhist Scholar, who put it this way: If there’s a remedy when trouble strikes, what reason is there for dejection? And if there is no help for it, what use is there in being glum? (Shantideva, The way of the Bodhisattva, p. 130). Clients who are religious or spiritually oriented may find particular comfort and insight in the words of Neibauer or Shantideva.
Yet another version of the Serenity Prayer comes from 20th century Philosopher W. W. Bartley. Bartley took a break from writing about philosophical rationalism, to put the message of the Serenity Prayer into a Mother Goose nursery rhyme format:
For every ailment under the sun
There is a remedy, or there is none;
If there be one, try to find it;
If there be none, never mind it.
When it comes to helping clients deal with complex contextual difficulties, these prayers or philosophies can be a good place to start, both for professionals, and for clients. Recognizing and accepting that some problems in life are unchangeable can bring solace. Trying to change that which is unchangeable generally fuels unhappiness.
The developers of mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2013) put their own brain-based 21st century spin on the Serenity Prayer. To summarize, they say the brain has two basic modes of functioning. The first mode is problem-solving. The brain is quite good at problem-solving. But some problems are unsolvable. When faced with insoluble problems, rather than letting go of the problem-solving process, the brain naturally persists, relentlessly continuing to problem-solve, ruminate, and chew on old ideas and failures. Anxiety and fear escalates. If the brain gets hooked on unsolvable problems, it can take clients down into bottomless rabbit-holes and exacerbate emotional discomfort.
What about that second basic brain modality? Mindfulness practitioners say that engaging the second mode can unhitch our brains from the out-of-control problem-solving train. The second brain modality operates on a less natural principle: The principle of acceptance. MBCT practitioners emphasize shifting into noticing, or nonjudgmental acceptance. Although the brain is capable of intermittent nonjudgmental acceptance, shifting into that modality is tough. Most clients can’t make that switch in the moment. That’s okay. Accepting failure to switch into nonjudgmental mindfulness is part of mindful acceptance. Coaching clients to make efforts at mindfulness and then to accept their failings and inadequacies might facilitate client self-acceptance and grow mindful parts of the brain, like the insula (Haase et al., 2016). Nonjudgmental acceptance requires regular practice. No one ever gets it right all the time.
Opportunity Ameliorates
James Garbarino (2001) wrote: “Stress accumulates; opportunity ameliorates” (p. 361). Within the trauma literature, it’s clear that toxic stress increases illness (Shern et al., 2016); it’s also clear that providing traumatized youth and adults with physical, social, and academic opportunities mitigates trauma and increases health. In part, your role with clients who have experienced trauma and who are chronically reactivated by socio-political events, is to assist them in finding and participating in local resources and opportunities.
Clients who are suicidal and in the midst of toxic and uncontrollable contextual factors, may feel they don’t have the time or energy for new opportunities. Like Katie from chapter 5, they may need support, assistance, and resources to step outside of their survival mode. Practical problems like childcare, transportation, and inaccessible community organizations can loom large. In such situations, you may need to engage in advocacy or activism to help your clients get connected to the resources and opportunities they need.
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John Sommers-Flanagan 