Category Archives: Writing

Dear Karen: I have a professional and personal responsibility to speak out against Unacceptable behaviors

Last week I received a comment on this blog. Getting a comment is always very exciting, partly because I don’t get all that many and partly because the comments are usually positive and affirming. In this case the comment was neither positive nor affirming.

Although getting critical comments isn’t nearly as fun and ego-boosting as affirming comments, receiving criticism is important to self-examination and growth. The person who commented last Thursday was upset about my “politics.” As many of you know, I’ve occasionally written about Mr. Trump and lamented his behavior. Sometimes, I’ve felt nervous posting critiques of Mr. Trump, worrying that I may have been behaving in ways that were less that professional and worrying that perhaps I shouldn’t openly express my negative opinions about his behavior. However, in the end, I’ve often ended up deciding that my critiques of Mr. Trump aren’t really about politics anyway.

Digesting Thursday’s comment has helped me clarify my position on political commentary. Here’s a version of what I wrote back to my blog commenter.

********************************************

Dear Karen,

Thanks for your message.

Many years ago when I interviewed Natalie Rogers, I recall her telling me something very compelling about her father, Carl Rogers. She said, in her family, all feelings were accepted, but not all behaviors.

Although some of my judgments about Mr. Trump have political components, most of my judgments about him focus on his personality and behavior. Politics aside, I wouldn’t care if he was a democrat, an independent, a republican, a corporate mogul, a teacher, a coach, or a rock star. I find his behavior to be an unacceptable example for children. From my perspective it’s clear that Mr. Trump is much more focused on using and abusing power than he is on empowering others. To return to Carl Rogers: Rogers believed the best use of power was to empower others. My perception of Mr. Trump is that he’s invested in accumulating power, and not on empowering others.

I could make a list of video evidence of Mr. Trump mocking disabled people, calling women “fat pigs,” disrespecting war veterans (including John McCain, whom I’ve never written a negative judgmental word about, despite his politics), paying off prostitutes, saying positive and supportive things about dictators and racists, and his continuous flow of lies. If Mr. Trump was my neighbor or a colleague at my University, it would be wrong for me to let his behavior pass without making it clear that I find his behaviors to be a potentially destructive and negative influence on children in the neighborhood or the culture at the University. Not only do I have a responsibility to be non-judgmentally accepting in therapeutic contexts, I also have a responsibility to speak up and speak out against racism and the promotion of violence. I believe there’s ample evidence that Mr. Trump has promoted racism and incited violence. My rejection of those behaviors isn’t particularly political; I simply believe that it’s morally wrong to promote racism and foment violence.

I can see we have different views of Mr. Trump. You may not see the evidence that I see, or you may find his behaviors less offensive and less dangerous. Although it’s challenging for me to understand your perspective, I know you’re not alone, and I know you must have reasons for believing the ways you believe. I can accept that.

But to articulate my perspective further, here’s a therapy example. If I was working with a client who exhibited no empathy or said things to others that were likely to incite violence, as a psychotherapist, I would work toward a greater understanding of the client’s emotions. In addition, I would consider it my professional responsibility to question those behaviors . . . for both the good of the client and the good of people in the client’s world.

Again, thanks for your message. It’s important to hear other perspectives and to have a chance to question myself and my own motives. I appreciate you providing me with that opportunity.

Happy Sunday,

John SF

An Alternative “Mother Goose” version of the Serenity Prayer

Friday night thoughts.

We put the following quote into our forthcoming book on Suicide Assessment and Treatment.

The quote is from 20th century Philosopher W. W. Bartley. Bartley took a break from writing about philosophical rationalism, to put the message of Neibuhr’s 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.”

Good advice.

I wish everyone peace and serenity for the weekend and beyond.

In This Sacred Hour . . .

Yesterday, for Halloween, I dressed up as agitation. I wasn’t alone. Everywhere I went, everyone I saw, and around every corner, I encountered agitation. Maybe it was herd mentality. But no one developed immunity.

This too shall pass, and it did. Last night I took a deep breath and exhaled, slowly. And then like all the best Yogis, I lingered on the outbreath. My costume, all the layers of agitation, melted away onto the floor, into the carpet, down through the flooring, seeping back to the earth where agitation can rest.

Today is my favorite day; a day to throw myself into the gift of an extra, socially constructed, sacred hour. In stark contrast to all my previous years on the planet, today I plan to stay here—in this sacred hour—all day.

Having fallen back, no matter how long in coming, this particular hour arrives with surprise. What shall I do in this dark hour before dawn? Shall I spend it now, or wait and spend it with Rita on a walk up the river. Which hour of this 24 will be my sacred, extravagant, unexpected hour?

Every year, I’ve rushed into this gift. Anticipating its disappearance even before it appears, I’ve tried squeezing enough productivity into one arbitrary hour to compensate for my perpetual time management problems. But this is a new year, a new day, and a new hour, and, after shedding my agitation costume, I now see peace. It’s a bumpy peace, much like the washboard road to East Rosebud Lake. We may get rattled, but we shall arrive.

What I’d never discerned before is that the sacred hour is an illusion. Like many things, the sacred hour was created out of nothing but time for someone’s convenience and instead of recognizing its nothingness, I’ve tried to grab it, wrestle it to the ground, and suck out its imaginary nutrients. Year after year, I’ve mulled its significance and then experienced angst over how to spend it. As I do with Mary Oliver’s query, “Tell me, what is it you plan to do. With your one wild and precious life?” I’ve demurred. The question is too big. Everything will eventually vanish, and if I choose one thing I’ll be left with only one companion: my own judgmental vengeance.

Peaceful, deep breathing is almost always about the outbreath. Fancy meditators and Yoga practitioners coach us to pace our breathing, and then to extend the outbreath into the place of no-breath. Oddly, the place of no-breath is the place of life and peace, if only for snippets at a time. While being still, without breathing, for a second or three or six before the in-breath comes again, the body’s physiology slows down, nearly halting in parasympathetic bliss. In the sacred space of the outbreath, peace happens in the body, and when peace happens in the body it can—with practice—transfer little seedlings of peace to the mind. The common admonishment, “Remember to breathe” is less profound than its uncommon sister: “Remember to not breathe.” Remember to let yourself extend your peace for a bit longer than usual today. Remember to be with peace tomorrow. Especially, remember to mingle with peace on Tuesday. You know why.

Today’s brief illumination is that there’s nothing special and nothing especially sacred about this extra hour. But also, like all hours, there’s everything special and sacred about this extra hour. It’s just another hour that, along with its pesky minutes and seconds, was simply created for the convenience of counting.  

I’ll probably forget all this by Tuesday, but for today, I see every hour is a collaborative creation. Every hour we get to return to the beginning, resetting our intentions, and refocusing on the mystery of what is and what might be.  

Tuesday, Wednesday, and beyond will bring as many sacred hours as we can count. How shall we spend those hours? For me, I hope we can collectively linger with our outbreaths on Tuesday as we begin, together and again, to build peace, reclaim justice, embrace empathy, and restore democracy . . . one bumpy and sacred hour at a time.

My Birthday Wish (and Request)

Yesterday, in anticipation of my 63rd trip around the sun, I started feeling a slow creep of melancholia. At my age, because all movements are slower than frozen molasses, I now have the luxury of spotting doom early on, as its ambling my way. Last night’s gloominess was mostly about aging, but amplified by my nightly dose of watching the evening news. As usual, the news inevitably featured Donald J. Trump being Donald J. Trump, and saying things that can’t—without the aid of a delusional disorder—be framed as anything other than mean, nasty, and dangerous. After yet again witnessing Mr. Trump’s malevolence, I turned to Rita and murmured, “I think he might be evil.”

As soon as the word evil escaped my mouth, I immediately thought of Carl Rogers. Rogers was an amazing American psychologist who, from the 1930s to the 1960s, developed a profoundly empathic way of working with people. Rogers was raised in a rigid fundamental conservative Christian family. He wasn’t allowed to dance or play cards. During college, at age 20 (the year was 1922), Rogers took a sharp ideological left turn while on a slow boat to China. He stepped away from his fundamentalist roots, and began embracing a broad and encompassing belief in the goodness of all people. Rogers stepped so far away from judgmentalism, and believed so deeply and persistently in the innate goodness of all humans, that many philosophers and psychologists in the 1950s and 1960s (like Rollo May and Martin Buber), viewed Rogers as dangerously naïve.

After realizing back in the 20th century that I would never be “Like Mike” (Michael Jordan), I started fancying myself as being like Carl Rogers instead. The match seemed perfect. Just like Rogers, I believe in everyone’s positive potential. Also like Rogers, I don’t really believe in evil. However, after four years of listening to someone with immense power mock the disabled, disparage the military, demean women, remorselessly lock migrant children in cages, stoke hate, division, and conspiracies, and threaten to blow up our democratic process . . . I’ve begun reconsidering my naïve Rogerian perspective on evil. Last night’s news snippet included Mr. Trump’s continued attack on the Michigan governor. As far as I can tell, the only times Mr. Trump manages to use his words to show empathy is when he’s reading—rather haltingly—off of a teleprompter.

Rogers might blanch at my judgment of Trump, but I think not. He wrote a book “On Personal Power” and his bottom line was that you should give it away. And when I interviewed his daughter, Natalie Rogers, in 2006, she made it clear that her dad was in favor of accepting and prizing all human feelings, but that he could be quite firm when people (and his children) behaved in unacceptable ways. I’m pretty sure that Carl Rogers, one of the most profoundly influential psychologists of all time, would be horrified by Mr. Trump’s behavior, and he would use his power to bring back civility, decency, and empathy.

A couple years ago I had the honor of meeting Joe Biden, face-to-face. He greeted me with flourish and enthusiasm. He oozed empathy, compassion, kindness, and a commitment to service. He spoke and acted without a whiff of arrogance. I’m convinced that he’s the sort of person who will use his power for good.

Here’s my birthday wish (and request). Instead of sending me all the lavish gifts you had planned to send me, just go out and spread the word that decency, empathy, respect, kindness, and love are making a HUGE comeback. And if you know someone whom you think isn’t voting, consider this: reach out with respect and kindness and ask them to vote for Joe Biden. That would be amazing . . . a little frosting on my birthday wish.

Thanks for reading this and for helping make my birthday wish come true.

Essential Information about Counseling and Psychotherapy Theories

A good summary is a beautiful thing. But summaries are always unfair and limited representations of that which is bigger. Nevertheless, below, I’ve tried to summarize the primary listening focus and the primary change mechanisms for each of 13 theoretical orientations included in our textbook, Counseling and Psychotherapy Theories in Context and Practice (John Wiley & Sons, 2018). In addition, yesterday I filmed myself using a memory-palace strategy while describing all 13 perspectives below. You can read the summary below and/or watch me try to pull off this 15 minute theories overview on YouTube: https://youtu.be/VJFK6cCHCU8

TheoryWhat to Listen For. . .Change Mechanisms
Psychoanalytic PsychodynamicOld maladaptive intrapersonal conflicts and repetitive, unconscious, and dysfunctional interpersonal patterns.Make unconscious conscious, catharsis, and working through new intra- and interpersonal dynamics.
AdlerianBasic mistakes imbedded in the style of life, including excess self-interest and inferiority/superiority.Awareness, insight, and encouragement (courage) to face the tasks of life.
ExistentialAnxiety over and avoidance of core existential life dynamics like death, isolation, meaninglessness, and freedom.Feedback and confrontation to help clients gain awareness and face life’s ultimate existential demands.
Person-CenteredEmotional distress, incongruence (discrepancies between real and ideal selves), and conditions of worth.A relationship characterized by congruence, unconditional positive regard, and empathic understanding.
GestaltUnfinished emotional and behavioral baggage from the past that blocks awareness or disturbs self-other boundaries.Guidance on using here-and-now experiments to deal with unfinished emotional and behavioral experiences.
BehavioralDisturbing emotions (e.g., anxiety), maladaptive behavior patterns, and environmental contingencies.New learning or re-learning via operant, classical, and social processes.
CBTDisturbing emotions (e.g., anxiety, anger), maladaptive thinking, maladaptive behaviors, and triggers/contingenciesCollaborative and empirical tasks that modify maladaptive or distorted cognitive information processing.
Choice Theory/Reality TherapyWhat clients want, what they’re doing, whether that’s working, and planning.Commit to and enact adaptive plans that are aligned with quality world goals.
FeministWhere is the client experiencing anger or dissatisfaction due to gender-based limits or oppressive situations?Relational connection and empowerment to actively seek personal goals and mutually empathic emotional relationships.
ConstructiveWhere clients are stuck and how existing client strengths, exceptions, and solutions can fuel change.Re-shaping, reframing, and reconsolidating old narratives and problem-based patterns through solutions and sparkling moments.
Family SystemsFamily dynamics, transactions, hierarchy, roles, and boundaries that contribute to personal or systemic dysfunction.Shift family dynamics and transactions via in-session and outside session assignments.
MulticulturalWhere is the client experiencing distress due to limiting or oppressive socio-political factors?Cultural acceptance, empowerment, and culturally-based rituals.
IntegrativeWhat are the client’s unique problems, strengths, and consistent ways of thinking, acting, and feeling?Match a therapeutic process to the client’s unique problems and strengths.

Guidelines for Giving and Receiving Feedback

Feedback 2

Giving and receiving feedback is a huge topic. In this blog post the focus is on giving and receiving feedback in classroom settings or in counseling/psychotherapy supervision. The following guidelines are far from perfect, but they offer ideas that instructors and students can use to structure the feedback giving and receiving process. Check them out, and feel free to improve on what’s here.

Before you do anything, remember that feedback can feel threatening. Hearing about how we sound and what we look like is pretty much a trigger for self-consciousness and vulnerability. Sometimes, when we look in the mirror, we don’t like what we see, and so obviously, when someone else holds up a mirror, the feedback we experience may be . . . uncomfortable. . . to say the least. To help everyone feel a bit safer, the following can be helpful:

  • Acknowledge that feedback is scary.
  • Emphasize that feedback is essential to counseling skill development.
  • Share the feedback process you’ll be using
  • Make recommendations and give examples of what kind of feedback is most useful.

Acknowledge that Feedback is Scary: You can talk about mirrors (see above), or about how unpleasant it is for most people to hear their own voices or see their own images, or tell a story of difficult and helpful feedback. I encourage you to find your own way to acknowledge that feedback triggers vulnerability.

Feedback is Essential: Encourage students to lean into their vulnerability and be open to feedback—but don’t pressure them. Explain: “The reason you’re in a counseling class is to improve your skills. Though hard to hear, constructive feedback is useful for skill development. Don’t think of it as criticism, but as an opportunity to learn from mistakes and improve your counseling skills.” What’s important is to norm the value of giving and getting feedback.

Share the Process You’ll be Using: Before starting a role play or in-class practice scenario, describe the guidelines you’ll be using for giving and receiving feedback (and then generate additional rules from students in the class). Here are some guidelines I’ve used:

  • Everyone who volunteers (or does a demonstration or is being observed) gets appreciation. Saying, “Thanks for volunteering” is essential. I like it when my classes established a norm where whoever does the role-playing or volunteers gets a round of applause.
  • After being appreciated, the role-player starts the process with a self-evaluation. You might say something like, “After every role play or presentation, the first thing we’ll do is have the person or people who were role-playing share their own thoughts about what they did well and what they think they didn’t do so well.”
  • After the volunteer self-evaluates, they’re asked whether they’d like feedback from others. If they say no, then no feedback should be given. Occasionally students will feel so vulnerable about a performance that they don’t want feedback. We need to accept their preference for no feedback and also encourage them to solicit and accept feedback at some later point in time.

Giving Useful Feedback: Feedback should be specific, concrete, and focused on things that can be modified. For example, you can offer a positive or non-facilitative behavioral observation (e.g., “I noticed you leaned back and crossed your arms when the client started talking about their sexuality.”). After making an observation, the feedback giver can offer a hypothesis (e.g., “Your client might interpret you leaning back and crossing your arms as judgmental”). The feedback giver can also offer an alternative (“Instead, you might want to lean forward and focus on some of your excellent nonverbal listening skills.”). BTW: General and positive comments (e.g., “Good job!”) are pleasant and encouraging, but should be used in combination with more specific feedback; it’s important to know what was good about your job.

Constructive or corrective feedback shouldn’t focus so much on what was done poorly, but emphasize what could be done to perform the skill correctly. Constructive or corrective feedback might sound like this: “I noticed you asked several closed questions that seemed to slow down the counseling process. Closed questions aren’t bad questions, but sometimes it’s easier to keep clients talking about important content if you replace your closed questions with open questions or with a paraphrase. Let’s try that.”

Other examples: Instead of saying, “Your body was stiff as a board,” try saying, “I think you’d be more effective if you relaxed your arms and shoulders more.” Or you could take some of the evaluation out of the comment by just noticing or observing, rather than judging, “I noticed you said the word, ‘Gotcha’ several times.” You can also ask what else they might say instead, “To vary how you’re responding to your client, what might you say instead of ‘Gotcha’?”

General negative comments such as “That was poorly done.” should be avoided. To be constructive, provide feedback that’s specific, concrete, and holds out the potential for positive change. Also, feedback should never be uniformly negative. Everyone engages in counseling behaviors that are more or less facilitative. If you happen to be the type who easily sees what’s wrong, but you have trouble offering praise, impose the following rule on yourself: If you can’t offer positive feedback, don’t offer any at all. Another alternative is to use the sandwich feedback technique when appropriate (i.e., say something positive, say something constructive, then say another positive thing).

IMHO, significant constructive feedback is the responsibility of the instructor and should be given during a private, individual supervision session. The general rule of: “Give positive feedback in public and constructive feedback in private” can be useful.

Finally, students should be reminded of the disappointing fact that no one performs perfectly, including the teacher or professor. Also, when you do demonstrations, be sure to model the process by doing a self-evaluation (including things you might have done better), and then asking students for observations and feedback.

 

 

Suicide Education Resources . . . and Why is it so Easy to Experience Imposter Syndrome?

100 Days: What Happens Next?

Elephants

For many, watching a sweaty Donald Trump give himself high praise for being able to pass a cognitive test that awards points for accurately identifying a picture of an elephant is oddly reassuring. Liberals, #NeverTrumpers, and other hopeful humans have had difficulty covering their glee. Mocking Trump’s person-woman-man-camera-TV buffoonery and how it illustrates his diminished or diminishing mental capacity is gratifying.

Speaking of buffoonery—because it’s more pleasant than what I’ll speak of next—a former student of mine sent me his proposal for a new cognitive test. He calls it the Idaho Cognitive Assessment (IdCA). Here’s what he wrote:

Listen, I’ve been making up five item memory tests for myself lately, and I ace them every time. For example, I’ll list off the names of my three kids, Monica, and our dog, and when I try to remember them a minute later, it’s easy for me. It’s not easy for everyone, but it’s easy for me. I even give myself extra points if I get them in order.

The IdCA is a fabulous and perfect parallel to the Donald Trump Cognitive Assessment (DtCA).  Using his clever spontaneity, Trump made up the DtCA on the spot while being filmed by a person, a woman, a man, a camera, and a TV. Just for the record, although the Montreal Cognitive Assessment (MoCA) isn’t especially difficult, it’s harder than the IdCA and the DtCA. But because Trump lies about everything we still don’t really know if could identify an elephant, remember five items, or pass the MoCA.

What I wish (and, I suspect, many others) is that Donald Trump was only a sweaty buffoon making a comedic cameo on Fox News. But, sadly, he’s more than a sweaty buffoon; he’s a dangerous sweaty buffoon, serial liar, and incompetent leader who’s putting the future of the United States and planet Earth at risk. What I fear is that while gloating over his buffoonery, we’ll forget that Trump is also an evil genius.

Trump is a once-in-a-century antisocial demagogue. If you don’t know what that means, check out my Slate article or this blog post: https://johnsommersflanagan.com/2018/11/05/my-closing-argument-take-a-breath-check-your-moral-compass-and-vote-for-checks-and-balances-in-government/.

Trump has a particularly unsavory personality type. Documentation of this personality type goes back to Aristotle’s student, Theophrastus (371 – 287 B.C.), who wrote:

The Unscrupulous Man will go and borrow more money from a creditor he has never paid . . . . When marketing he reminds the butcher of some service he has rendered him and, standing near the scales, throws in some meat, if he can, and a soup-bone. If he succeeds, so much the better; if not, he will snatch a piece of tripe and go off laughing (from Widiger, Corbitt, & Millon, p. 63).

About 2000 years later, the famous American physician, Benjamin Rush, picked up on Theophrastus’s theme, becoming intrigued with what was briefly called moral insanity. In cases of moral insanity, individuals are capable of clear and lucid thought, but repeatedly engage in irresponsible, immoral, and destructive behaviors without experiencing guilt or shameless. These shameless criminals act boldly, but without moral compass, believing that only they could possibly divine the true and correct way forward. In an apt description of Trump’s everyday behavior, Rush wrote: “Persons thus diseased cannot speak the truth upon any subject” (1812, p. 124).

Although predicting the future is always inexact, Trump’s personality type provides a reasonable foundation. That being the case, my personality-based predictions for Trump’s future behaviors are below—along with ways in which we, as U.S. citizens interested in the continuation of a democratic republic—can respond.

  1. Trump will tell more and bigger lies. As threats to his presidency and risks of defeat loom, Trump’s lies will grow in size and frequency. The good news is that Trump’s lies will grow more obvious, and hopefully the American public and media can leverage them to further grow opposition.
  2. Trump will continue to show poor judgment, principally because he’s the only one who living in his personal decision-making echo chamber. Trump’s logic and gut are impaired. His decisions will continue to often be wrong and dangerous. The good news about Trump’s poor judgment is that if the media can pounce on his upcoming egregiously bad decisions, the public may continue to grow in their distrust of him.
  3. Trump will deflect responsibility. Trump’s moral philosophy includes complete opposition to taking responsibility for mistakes. This pattern will continue. As in the past, he’ll blame others (e.g., Obama, Biden, Clinton) for things they’ve never done. In many cases, his deflecting responsibility will include abject projection (Crooked Hillary was clearly a projection by Crooked Donald). Trump’s tendency to project his own criminal behavior onto others can provide leads to what he’s doing. Also, and this is critical, EVERYTHING Trump does needs to be framed as the responsibility of every individual member of the GOP, until and unless they split from him.
  4. To compensate for his slagging physical and intellectual abilities, Trump will become increasingly desperate to look strong. The bad news is that Trump posturing may translate into more tear gas, more fomenting of foreign conflict, and more steps toward martial law. The good news is that he cannot stop himself from looking and acting pathetic . . . and as organizations like the Lincoln Project target Trump’s weakness and pathetic efforts to appear competent, they’re proving their exceptional media savvy.
  5. Trump will stoke division and inflame hatred. This is a common Trumpian strategy. The good news is that many Americans are aware of this strategy and can compensate with unification. The other good news is that if polls continue downward, Trump won’t be able to resist stoking division within his own ranks.
  6. Trump will continue to seek profit and praise to assuage his battered ego. Again, the more desperate his follows this path, the more likely he is to make mistakes, and the more opportunities there are to catch him, red-handed, in criminal activity.
  7. Trump will continue in his role as influence-peddler in chief. Trump will use money, power, legal intimidation, and any leverage he can find to recruit and embolden followers. The details of how he accomplishes this and the psychological vulnerability of ForeverTrumpers is grist for another mill, but count on it to continue, and count on it to continue to seem completely irrational.

I know there’s nothing much new here. But the point is that now and into the future we need to maintain a planned and proactive attack on Trump’s competence, with unwavering focus on catching him and holding him accountable for the many lies, mistakes, and criminal activities he will be engaging in for the next 100 days. We know Trump is an immensely narcissistic compulsive liar who lacks basic self-awareness and seems unable to muster up empathy or compassion for anyone other than his loyal, criminal, and sycophantic followers—even when those followers happen to have deep links to pedophilia or the Russian mob. However, we also know that these traits were in place four years ago, and he was elected anyway. That’s why, right now, as we enter the home-stretch, we all need to be focused like a laser on deconstructing his genius while simultaneously, exposing his weaknesses, his criminal activities, and every manifestation of his pathetic buffoonery . . . as he makes his way down the slippery metaphoric ramp toward November 3, 2020.

Trump on Ramp

To Mask or Not to Mask: Making America Rational Again

Make America Rational Again

About 4 years ago, I made a MARA hat. MARA stands for “Make America Rational Again.” My hat was in honor of the late Albert Ellis, a famous psychologist who relentlessly advocated for rational thinking. Given that some folks are doubting Covid-19, while others are passionately accusing health officials of infringing on their God-given liberties, I’m thinking my MARA hat from the last presidential election is still in style.

Way back when I was a full-time therapist working mostly with teenagers, I developed a method for talking with my teen-clients about their freedoms. When they complained about their parents infringing on their rights—those damn parents were pronouncing unreasonable curfews, alcohol prohibitions, and other silly mandates—I’d say something like this:

“Really, you only have three choices. You can do whatever your parents think you should do. That’s option #1. Or, you can do the opposite of what your parents think you should do. That’s option #2. Those are easy options. You don’t even have to think.”

Hoping to pique the teen’s interest, I’d pause and to let my profound comments linger. Sometimes I got stony silence, or an eye-roll. But usually curiosity won out, and my client would ask:

“What’s the third choice?”

“The third choice is for you to make an independent decision. But that’s way harder. You probably don’t want to go there.”

Actually, most of my teenage clients DID want to go there. They wanted to learn, grow, develop, and become capable of effective decision-making. Sadly, that doesn’t seem to be the case today. All too often, Americans are basing their decision-making on poor information. For example, when people are gathering the 411 on whether they should mask-up in public settings, to where do they turn? The rational choice would be medical professionals and virologists. But instead, people are turning to Facebook, Twitter, and even worse, Fox News, where misinformation from Tucker Carlson, Laura Ingraham, and Sean Hannity is offered up with nary a shred of journalistic ethics or integrity (for a fun and fabulous SNL Parody with Kate McKinnon as Laura Ingraham, check out this link: https://www.youtube.com/watch?v=XezLiezWN0E).

A related question that’s especially pressing right now is this: “How should we respond to coronavirus deniers and rabid anti-maskers?” Speaking for myself, I’ve been struggling to find the right words. Saying what I’m thinking—which usually starts with “WTF!? Have you been listening to Tucker Carlson instead of Dr. Fauci?”—seems too offensive and unhelpful. Instead, I’m making a commitment to letting go of the outrage, putting my 2016 campaign hat back on, and making myself rational again. Instead of being angry, my plan is to retreat to rationality. I’ll say things like this: “Hey, I’m curious, have you read the latest article in the New England Journal of Medicine titled, “Observational study of hydroxychloroquine in hospitalized patients with Covid-19?” or, “What are your thoughts about the chilblain-like lesions doctors are finding on patients with Covid-19?” or “According to the CDC and Dr. Fauci and the American Medical Association, the cloth face coverings—although imperfect—statistically reduce the likelihood of spreading the coronavirus.”

I invite you to join me in gathering good data for our personal and social decision-making. Together, we can Make America Rational Again.

Individualizing Suicide Risk Factors in the Context of a Clinical Interview

Spring 2020

In response to my recent post on “The Myth of Suicide Risk and Protective Factors” Mark, a clinical supervisor from Edmonton, wrote me and asked about how to make individualizing suicide risk factors with clients more concrete/practical and less abstract. I thought, “What a great question” and will try to answer it here.

Let’s start with two foundational prerequisites. First, clinical providers need to be able to ask about suicide in ways that don’t pathologize the patient/client. Specifically, if clients fear that disclosing suicide ideation will result in them being judged as “crazy” or in involuntary hospitalization, then they’re more likely to keep their suicidal thoughts to themselves. This fear dynamic is one reason why we emphasize using a normalizing frame when asking about suicide.

Second, both before and after suicide ideation disclosures, providers need to explicitly emphasize collaboration. Essentially, the message is: “All we’re doing is working together to better understand and address the distress or pain that underlies your suicidal thoughts.” In other words, the focus isn’t on getting rid of suicidal thoughts; the focus is on reduction of psychological pain or distress.

With these two foundational principles in place, then the provider can collaboratively explore the primary and secondary sources of the client’s psychological pain. In our seven-dimensional model, we recommend exploring emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual sources of pain. Collaborative exploration is fundamental to individualizing risk factors. The general statistics showing that previous attempts, social isolation, physical illness, being male, and other factors predict suicide are mostly useless at that point. Instead, your job as a mental health provider is to pursue the distress. By pursuing the distress, you discover individualized risk factors. The following excerpt from our upcoming book illustrates how asking about “What’s bad” and “What feels worst?” results in individualized risk factors.

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     The opening exchange with Sophia is important because it shows how clinicians—even when operating from a strength-based foundation—address emotional distress. In the beginning the counselor drills down into the negative (e.g., “What’s making you feel bad?”), even though the plan is to develop client strengths and resilience. By drilling down into the client’s distress and emotional pain, and then later identifying what helps the client cope, the counselor is individualizing risk and protective factor assessment, rather than using a ubiquitous checklist.

Counselor: Sophia, thanks for meeting. I know you’re not super-excited to be here. I also know your parents said you’ve been talking about suicide off and on for a while, so they wanted me to talk with you. But I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so if you’re willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is you’re feeling?

The counselor began with an acknowledgement and quick summary of what he knew. This is a basic strategy for working with teens (Sommers-Flanagan & Sommers-Flanagan, 2007), but also can be true when working with adults. If counselors withhold what they know about clients, rapport and relationship development suffers.

The opening phrase “I don’t know. . .” acknowledges the limits of the counselor’s knowledge and offers an invitation for collaboration. Effective clinicians initially and intermittently offer invitations for collaboration to build the working alliance (Parrow, Sommers-Flanagan, Sky Cova, & Lungu, 2019). The underlying message is, “I want to help, but I can’t be helpful all on my own. I need your input so we can work together to address the distress you’re feeling.”

The opening question for Sophia is negative (i.e., What’s making you feel bad or sad or miserable or whatever it is you’re feeling?). This opening shows empathy for the emotional distress that triggers her suicidality and clarifies the link between her emotional distress and the triggering situations. By tuning into negative emotions, the counselor hones in on the presumptive primary treatment goal for all clients who are suicidal—to reduce the perceived intolerable or excruciating emotional distress (Shneidman, 1993).

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Collaborative exploration is the method through which risk and protective factors are individualized. If Sophia had a previous attempt, the reason to explore the previous attempt would be to discover what created the emotional distress that provoked the attempt, and how counseling or psychotherapy might address that particular factor. For example, if bullying and lack of social connection triggered Sophia’s attempt, then we would view bullying and social disconnection as Sophia’s particular individualized risk factors. We would then build treatments—in collaboration with Sophia and her family—that directly address the unique factors contributing to her pain, and provide her with palpable therapeutic support.

I hope this post has clarified how to individualize suicide risk factors and use them in treatment. Thanks for the question Mark!