During a couple of my presentations at the ACA conference in Toronto (pictured above) I wasn’t able to fit in some short demonstration videos. To address my time management problems, I’m posting links to them here, along with a short description. Note: All of the videos for suicide demonstrations are non-scripted simulations.
Video 1: An example of an opening of a session with Kennedy, a 15-year-old cisgender white female with a history of suicidal ideation. Key things to watch for include how I immediately mention suicide, focus on sources of distress in Kennedy’s life, and acknowledge things I know and things I don’t know. If we think about emotional distress (aka Shneidman’s psychache) as contributing to suicidality, contemplate what you think is the driver of Kennedy’s feelings of suicidality. The link: https://www.youtube.com/watch?v=gR7YU0VrHqw&t=5s
Video 2: An example of me closing the session with Kennedy using Stanley & Brown’s (2013) Safety Planning Intervention. As always, I’m not perfect in the video, but it shows a process during which I’m trying to cover the safety planning categories in an interpersonally engaging and pleasant manner. The link: https://www.youtube.com/watch?v=jd7PM9HFDO4&t=10s
Video 3: I’m working with Chase, a 35-year-old Gay cisgender male. In this video, I try to get Chase to see a potential pattern of him being suicidal in response to bullying in the past and being interpersonally invalidated in the present. Chase dismisses my “light interpretation” with something like, “That’s the hand I was dealt.” Again, although I’m imperfect in this video, I do take the hint and shift from an abstract interpretation to a concrete assessment process I call the “Social Universe.” During that process, it becomes clear that Chase is spending too much time with “toxic” people in his life and not much time with people who accept him. Additionally, he presents as quite depressed and unable to come up with anyone “validating” and so I shift to a process called, “Building hope from the bottom up” by asking him, “Who’s the least validating or most toxic?” Chase responds pretty well to a process that starts at the bottom or most negative place.” The link: https://www.youtube.com/watch?v=UNBR3bKyE4I&t=7s
Thanks to everyone who attended the ACA conference, for being the kind of professionals who are pursuing awareness, knowledge, and skills in order to be more effective in helping others life meaningful lives. I was humbled by your engagement with the learning process.
Tomorrow morning, March 31, 2023, at 8am, I’m co-presenting with Matt Englar-Carlson and Dan Salois on suicide and happiness with men at the American Counseling Association World Conference in Toronto.
Here’s the session blurb:
Men and boys account for nearly 80% of all suicide deaths in the U.S. Factors contributing to high suicide rates include: constricted emotional expression, reluctance to seek help, firearms, alcohol abuse, and narrowly defined masculinity. In this educational session, we will use a case demonstration to illustrate suicide assessment counseling methods to help boys and men liberate themselves from narrow masculine values, while embracing alternative and meaningful paths to happiness.
If you’re in Toronto, I hope to see you there. . . and for anyone interested, here’s the Powerpoint presentation:
I’m really not sure what’s happening with WordPress, but because of tech and formatting issues, this is my third effort to post this blog. Now, I’m trying an approach that requires me to separately copy and paste each paragraph into this post. I used to be able to paste the whole document and it worked just fine. Now, if I do that, it makes all 10 paragraphs into one long paragraph and I look technologically even dumber than I am. Next month, WordPress will likely make me copy and paste the blog word by word.
You may be wondering, “How are you doing John?”
I think I’ll pass on answering that for now because WordPress is now graying out each sentence I type as soon as I press “enter.” And it’s repeating some short paragraphs and even though I delete them and they appear to be gone, when I try to publish this, the deleted paragraphs re-appear. I don’t know what any of this means other than WordPress must be angry with me because I asked them for help.
What I’ve been wanting to post is that I’m honored to be speaking several times at the American Counseling Association World Conference in Toronto next week. Here’s what’s happening. . .
Bright and early Friday morning, March 31 from 8am to 9:30am, I’ll be joined by Matt Englar-Carlson of Cal State Fullerton and Dan Salois of the University of Montana, for an educational session titled, “Men, Suicide, and Happiness: Helping Men Live Meaningful Lives.” We’ll be starting our talk by wondering why there isn’t more focus on the fact that men die by suicide at 3+ the rates of women and by wondering who gets to define what constitutes intimacy and intimate conversations among men. If you come to our talk and are not fully satisfied, you just might win an evening out getting a beer with us as we lament the unpopularity of masculine psychology. Or you might not. Life is like that.
At 1pm to 1:30pm on Friday I have the great fortune of joining Amanda Evans and Kenson Hiatt of James Madison University for a poster session titled, “Wellness and Social Justice: A Positive, Liberation-Oriented Approach.” Among the many things that are cool about this presentation is the fact that Dr. Evans has creatively combined social justice, positive psychology, and liberation psychology in ways that—as far as I know—have never been done before. Given the usual awkward nature of poster sessions, I hope you’ll drop by for some conversations about how we can integrate these important perspectives and facilitate social justice. But if you’re the type who prefers walking and studiously avoiding eye-contact with poster presenters, that works too.
From 3:30pm to 5pm on Friday, I have the privilege of offering an “Author Session” titled, “Top Tips for Weaving a Strengths-Based Approach to Suicide into Your Practice.” This session—based on our ACA book by nearly the same name, I will offer strengths-based tips about viewing suicidality as an unparalleled counseling opportunity, making your assessments therapeutic, building hope from the bottom-up, and much more. Right afterward, there will be a book-signing session . . . and I hope you’ll come to that, if only to talk to me and save me from the embarrassing situation of sitting alone next to a pile of books.
On Saturday, April 1 (and this is no joke), I’ll be presenting an education session on “Counseling for Happiness: Facilitating Client and Student Wellness.” Here’s the blurb:
Most people who seek counseling not only want to deal with their problems and distress, they also want to live happier and more meaningful lives. In this education session, the presenter will describe and demonstrate six evidence-based happiness strategies that professional counselors can use with clients and with themselves. The discussion will also address how specific happiness interventions may be more or less culturally appropriate. Using an open and collaborative experimental mindset is encouraged.
In addition to these formal appearances, I will also be hanging out at the John Wiley and Sons booth in the exhibition hall (especially on Thursday, March 30, from 2-5pm for the Expo Grand Opening). If you happen to be in Toronto for the ACA Conference, I hope to see you there.
Engaging clients in a collaborative safety planning process is an evidence-based suicide intervention. The typical gold standard for safety planning is the Safety Planning Intervention (SPI) by Stanley and Brown (2012). You can access free material on the SPI and learn how to obtain professional training for using SPIs at this link: https://suicidesafetyplan.com/
As a part of the 7.5-hour Assessment and Intervention with Suicidal Clients video published by psychotherapy.net, I did a short (about 7 minute) demonstration of safety planning with a 15-year-old cisgender female client. The demo comes at the end of the session and naturally, I already know lots of information that can be integrated into the safety plan. Nevertheless, introducing and completing the safety plan is an excellent organizing experience.
In part, safety planning emerged as an alternative to what were called “No-suicide contracts.” No suicide contracts fell out of favor in the mid-to-late 1990s, because many clients/patients viewed them as coercive and liability-dodging behaviors by clinicians, and because they focused on what NOT TO DO, instead of what clients/patients should do, when feeling suicidal. Safety planning involves proactive planning for what clients can do to effectively cope during a suicidal crisis.
Victor Yalom of psychotherapy.net has given me permission to offer this video clip to everyone as a free resource to guide and inspire you as you work to develop your skills for collaborative safety planning. You can find a glittering array of videos, including the previously mentioned, three-part 7.5 hour classic at: https://www.psychotherapy.net/ and https://www.psychotherapy.net/video/suicidal-clients-series
Reframing, as a counseling and psychotherapy intervention, involves nudging clients toward viewing their thoughts, emotions, behaviors, and life situations from a different or new perspective. Reframing is an especially popular technique among cognitive, existential, and solution-focused therapists. In the following excerpt from our book on the strengths-based approach to suicide assessment and treatment, we discuss reframing . . . and what to do when it fails.
***********************
Framing Pain and Suicidality as Evidence of a Normal Self-Care Impulse
Another reframe involves viewing suicidality as coming from a place of self-care or self-compassion. Using your own words, you might try a reframe like this:
As you talk about wanting to die, I’m struck that your wish for death also comes from your wish to feel better . . . and your wish to feel better is normal, natural, and healthy. What I’d like to do for now, is to partner with you on the healthy goal of feeling better. I need your help on this. For now, we can put your wish to die on the sidelines, and focus on feeling better. We can’t expect immediate positive results. Will you work with me to battle your pain, and little by little, to help you feel better?
This reframing message is intentionally repetitive, and almost hypnotic. The purpose is to engage with and activate the healthy part of the self that wants to feel better. When clients respond to this message, hope for positive outcomes may increase. If clients reject this reframing message, suicide risk may be high.
Framing Pain as Meaningful
Victor Frankl (1967) used reframing to address depressive symptoms in the following case.
An old doctor consulted me in Vienna because he could not get rid of a severe depression caused by the death of his wife. I asked him, “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?” Whereupon he said: “For her this would have been terrible; how she would have suffered!” I then added, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now you have to pay for it by surviving and mourning her.” The old man suddenly saw his plight in a new light, and reevaluated his suffering in the meaningful terms of a sacrifice for the sake of his wife. (1967, pp. 15–16)
Consistent with Frankl’s existential perspective, his reframe involves viewing suffering as meaningful. If clients view suffering as meaningful, life can feel more bearable.
When Reframes Fail
Reframing and redefining client emotional distress takes many forms. But, sometimes reframes don’t fit and don’t work. Reframes may be ineffective due to: (a) cultural insensitivity, (b) symptom severity, (c) inadequate rapport or alliance, and (d) countertransference (Lenes et al., 2020; Parrow et al., 2019). When your efforts to reframe fail, clients may withdraw or become agitated and you may risk a relationship rupture (Safran & Kraus, 2014). If the reframe doesn’t fit, process the issue (e.g., “Based on your reaction, it doesn’t seem like the idea I shared fits well for you”). After listening to your client’s response, you might need to proceed with strategies for rupture repair (see Sommers-Flanagan & Sommers-Flanagan, 2017). Relationship repair might include a direct apology and further processing. For example,
I’m sorry my idea for how to think about your pain wasn’t a good fit. But I’m glad you let me know it doesn’t fit. Lots of counseling is like an experiment. Sometimes we discover something doesn’t work. If you think something doesn’t fit or work for you, I will always want to know. Thank you for telling me.
When it comes to using reframing and redefinitions, your theoretical foundation is less important than the pragmatics of finding something that works for your client. The process involves: (a) identifying a potential reframe, (b) asking clients permission to try it out; (c) sharing the reframe; (d) observing client reactions, (e) verbally checking on client reactions and goodness of fit; (f) continuing to collaboratively experiment with the reframe or collaboratively discard it as a bad idea; and (g) addressing the relationship rupture—if one occurred.
********************
If you’re interested in our suicide book, give it a Google. Given the our unique hyphenated last name, it’s not hard to find.
I’m in Helena today, learning and presenting at the Montana CBT Conference. This is a very cool event, organized by Kyrie Russ, M.A., LCPC, and including about 35 fantastic Montana professionals interested in deepening their knowledge of CBT principles and practice.
I’m presenting twice; below I’ve included links to my two sets of ppts (which may be redundant/overlapping with ppts I’ve posted here before).
Exploring the Potential of Evidence-Based Happiness
While searching for updated guidance on cross-cultural eye contact in counseling and psychotherapy (for the 7th edition revision of Clinical Interviewing), I came across a young therapist with over 1 million YouTube subscribers. She was perky, articulate, and very impressive in her delivery of almost-true information about the meaning of eye contact in counseling (from about 5 years ago). There were so many public comments on her video . . . I couldn’t possibly read or track them all. Sadly, although she waxed eloquent about trauma and eye contact, she never once mentioned culture, or how the meaning of eye contact varies based on cultural, familial, and individual factors. Part of my takeaway was her retelling a version of a John Wayne-esq sort of message wherein we should all strive to look the other person in the eye. Ugh. I’m sad we have so many perky, articulate influencers who share information that’s NOT inclusive or deep or particularly accurate. Oh well.
Curious, and TBH, perhaps a bit jealous of this therapist’s YouTube fame, I clicked on her most recent video. I discovered her in tears, describing how she needs a break, and detailing a range of symptoms that fit pretty well with major depressive disorder. Oh my. This time I felt sad for her and her life because it must have turned into a runaway train of influencer-related opportunities and demands. My jealousy of her particular type of fame evaporated.
Many therapists—including me—aren’t as good at practicing as we are preaching. Every day I try to get better and fail a little and succeed a little. Life is a marathon. Small changes can make their way into our lives and become bigger changes.
Because of our Clinical Interviewing revision, I’m saying “No” to presentation opportunities more often than usual. That’s a good thing. Setting limits and taking care of business at home is essential. However, in about one month, I’ve set aside a week for a gamut of presentations and appearances. These presentations and appearances all include some content related to positive psychology, positive coping, and how we can all live better lives in the face of challenging work. Here they are:
On Friday, November 4 at 8:30am, I’ll be doing an opening keynote address for the Montana CBT conference. The keynote is titled, “Exploring the Potential of Evidence-Based Happiness.” The whole conference looks great (12.75 CEs available). I’ve also got a break-out session from 1:15pm to 3:15pm, titled, “Using a Strengths-Based Approach to Suicide Assessment and Treatment in Your Counseling Practice.” You can register for the two-day Montana CBT conference here: https://www.eventbrite.com/e/montana-cbt-conference-registration-367811452957Helena
On Monday, November 7 at 11am in Missoula I’ll be presenting for the University of Montana Molli Program. Although in-person seats are sold-out, people can still register to attend online. https://www.missoulaevents.net/11/07/2022/the-art-science-and-practice-of-meaningful-happiness/ The presentation title is: The Art, Science, and Practice of Meaningful Happiness. Molli is the Osher Lifelong Learning Institute at UM – which focuses on educational offerings for folks 50+ years-old.
One more freebie in honor of suicide prevention month.
Building hope from the bottom up is one of the strengths-based suicide assessment and treatment techniques clinicians like best. I may be forgetting that I’ve already posted this here, but the approach is so popular that I’ll take that risk. Here’s the section for our Strengths-Based Suicide book . . .
Working from the Bottom Up to Build a Continuum ofHope
When clients are depressed and suicidal, they often think and talk about depressing thoughts and feelings. We shouldn’t expect otherwise. Even so, when clients ruminate on the negative, it fogs the window through which positive feelings and experiences are viewed. Within counseling, a potential conflict emerges: although clinicians want clients to problem-solve, focus on their strengths, and have hope for the future, clients are unable to generate solutions, can’t focus on their strengths or positive attributes, and seem unable to shake their hopelessness.
As discussed earlier in the case of Sophia, after an initial discussion of suicidality, there may come a natural time to pivot to the positive. One common strength-based tool for exploring what helps clients overcome their suicidality is a solution-focused question (Sommers-Flanagan, 2018a). If you’re working with a client who has made a previous attempt, you might ask something like “You’ve tried suicide before, but you’re here with me now, so there’s still a chance for a better life. What helped in the past?”
Although this is a perfectly reasonable question, the question may fall flat, and your client might respond with a hopelessness statement, “Nothing really ever helps.” This puts you in a predicament. Should you use Socratic questioning to identify a cognitive distortion? Should you interpret the distorted thinking in the here-and-now? Or should you retreat to empathy?
No matter what theoretical model you’re using, the predicament of how to deal with client non-responsiveness, negativity, or cognitive distortions remains. Let’s say you’re operating from a solution-focused or strength-based model and you ask the miracle question:
I’m going to ask you a strange question. What if, after we get done talking, you go back to doing your usual things at home, go to bed, and get some sleep. But in the middle of the night, a miracle happens, and your feelings of depression and suicide go away. You were asleep, and so you don’t know about the miracle. When you wake up, what will be the first thing you notice that will make you say to yourself, “Wow. Something amazing happened. I’m no longer depressed and suicidal.” (adapted from Berg & Dolan, 2001, p. 7).
Although the miracle question might do its magic and your client will respond with something positive, it’s equally possible that your client will say something like, “Not possible” or “The only way that would happen would be if I died in the night.” When clients are pervasively negative and hopeless, one error clinicians often make is to get into a yes-no questioning process that looks something like this:
Counselor: I’m sure there must be something that helps you feel more positive.
Client: I can’t think of anything.
Counselor: How about time with friends, does that help?
Client: No. I don’t have any real friends left.
Counselor: How about exercise?
Client: I can’t even get myself to exercise.
Counselor: Being in the outdoors helps with depression. Does that help?
Client: Nope.
Counselor: Have you tried medications?
Client: I hate medications. They made me feel like a zombie.
Entering into this exchange is unhelpful. In the end, both you and your client will be more depressed. Rather than continuing to ask what helps, try changing the focus to what doesn’t help. This shift is useful because when clients are experiencing suicidal depression, they’re more likely to resonate with negativity, and connecting with your client at the negative bottom is better than not connecting at all. The goal is to collaboratively build a continuum from the bottom up. By starting at the bottom, you’re simultaneously assessing hopelessness and intervening on the “Black-black” (as opposed to black-white) distorted thinking that you’re witnessing in session. Here’s an example:
Counselor: You’ve tried lots of different strategies to deal with your suicidal thoughts, without success. You’ve tried medications, exercise, and you’ve talked to your rabbi. Let’s list these and other things you’ve tried, and see which strategies were the worst. Of all the things you’ve tried, what was worst?
Client: I really hated exercising. It felt like I was being coerced to do something I’ve always hated. And it made me sore.
Counselor: Okay then. Exercise was the worst. You hated that. Of the other things you’ve tried, what was a little less bad than exercising?
Client: The medications. I just didn’t feel like myself.
Counselor: So that didn’t work either. So, of those three things, talking with your rabbi was the least bad?
Client: Yeah. It didn’t help much. But she was nice and supportive. I felt a little better, but I didn’t want to keep talking because she’s busy and I was a burden.
Focusing on the worst option resonates with a negative emotional state. For clients who are unhappy with the results of previous therapeutic efforts, beginning with the most worthless strategy of all is an easier therapeutic and assessment task, provides useful information, and is usually answered quickly. Subsequently, clinicians can move upward toward strategies that are “just a little less bad.” Building a unique continuum of what’s more and less helpful is the goal. Later, you can add new ideas that you or your client identify, and put them in their place on the continuum. If this approach works well, together with your client you will have generated several ideas (some new and some old) that are worth experimenting with in the future.
Beginning from the bottom puts a different spin on the problem-solving process. Even extremely depressed clients can acknowledge that every attempt to address their symptoms isn’t equally bad. Using a continuum is a useful tool for working with hopelessness and is consistent with the CBT technique, “Thinking in shades of grey.”
I’m in Enterprise, Oregon today and tomorrow morning. I got here Sunday evening after a winding ride through forests and mountains. Yes, I’m in Eastern Oregon. Even I, having attended Mount Hood Community College and Oregon State University, had no idea there were forests and mountains in Enterprise.
The scenes are seriously amazing, but the people at the Wallowa Valley Center for Wellness-where I’m doing a series of presentations on suicide assessment and prevention-are no less amazing. I’ve been VERY pleasantly surprised at the quality, competence, and kindness of the staff and community.
Just in case you’re interested, below I’m posting ppts for my three different presentations. They overlap, but are somewhat distinct.
John Sommers-Flanagan 