Category Archives: Writing

Evaluating Interpersonal Dynamics in the Initial Clinical Interview

As we begin the revision process for Clinical Interviewing, I’m discovering content here and there that I want to share. Below is a short excerpt from the Intake Interviewing chapter where we’re discussing the process of evaluating clients’ interpersonal behavior patterns. Please email me your reactions and recommendations if you have some.

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Evaluating Interpersonal Behavior

Interpersonal behavior is central in the development and maintenance of client problems. Some theorists claim that all client problems have their roots in relationship problems (Glasser, 1998). Evaluating client interpersonal behavior is an essential part of an intake interview.

Intake interviewers have five potential data sources pertaining to client interpersonal behavior.

  1. Client self-report. This includes self-report of (a) past relationship interactions (e.g., childhood) and (b) contemporary relationship interactions.
  2. Clinician observations of client interpersonal behavior during the interview.
  3. Formal psychological assessment data.
  4. Information from past psychological records/reports.
  5. Information from collateral informants.

Although some behaviorists and in-home family therapists also observe clients outside the office (e.g., in school, home, and work environments), it’s unusual to have those data available prior to an intake.

Evaluating interpersonal behavior is difficult. Each of the preceding data sources can be suspect. For example, client self-report may be distorted or biased; often clients cast their interpersonal behaviors in a favorable light, or they may excessively blame themselves for negative interpersonal experiences. Clinician observations are also subjective. When you’re evaluating client interpersonal behavior, it’s wise to use several basic assessment principles to temper your conclusions:

  1. Single observations are often unreliable. This is partly because interpersonal behavior can shift dramatically from situation to situation. Multiple observations of behavior patterns (e.g., interpersonal aggression or interpersonal isolation) are more reliable.
  2. Just as construct validity is established through multimethod, multitrait assessments (Campbell & Fiske, 1959), interpersonal assessments are more valid when you have converging data from more than one source (e.g., self-report plus clinician observation).
  3. The literature is replete with theory-based models for interpersonal assessment. When clinicians hold strong theoretical beliefs, confirmation bias is more likely (in other words, you will make observations that confirm your theoretical stance or hypothesis). Therefore, you should regularly question conclusions about client interpersonal behavior based on your preexisting ideas.

One of the most popular models for conceptualizing interpersonal behavior is attachment theory. Adherents to this perspective believe that early caregiver-child relationship interactions create internal working models about how relationships work. Essentially, this leaves clients with consistent (and sometimes rigid) interpersonal expectations and reactions. For example, clients with insecure attachment styles may expect or anticipate rejection or abandonment, while clients with ambivalent attachment styles alternate between pushing others away and clinging to them. Typically, maladaptive components of client internal working models are activated during the early stages of new relationships or during times of significant stress, when support and reassurance are needed (O’Shea, Spence, & Donovan, 2014).

Interpersonal assessment based on attachment theory is a psychodynamic approach and involves a depth-oriented assessment process. However, the idea that individuals have internal working models that guide their interpersonal behaviors is consistent across many different theoretical perspectives. Specifically,

  • Cognitive therapists emphasize client schema or schemata that shape what clients expect in interpersonal relationships (Young, Klosko, & Weishaar, 2003).
  • Adlerian therapists use the term lifestyle assessment to refer to the evaluation of client expectations about the self, the world, and others (Carlson, Watts, & Maniacci, 2006).
  • Psychoanalytic therapists refer to the client’s core conflictual relational theme (CCRT) as a target for treatment (Luborsky, 1984).
  • The whole emphasis of the empirically supported interpersonal psychotherapy for depression is based on addressing problematic interpersonal relationship dynamics (Markowitz & Weissman, 2012).

It’s always advisable to attend to feelings and reactions that clients elicit in you (Teyber & McClure, 2011). For example, some clients may trigger boredom, arousal, sadness, or annoyance. These personal and emotional reactions can be viewed as countertransference (Luborsky & Barrett, 2006). However, if there’s convergent evidence that reactions the client is evoking in you are also evoked in others, it’s likely that the client’s interpersonal behavior is the culprit. If your reactions are unique, then your countertransference reaction may be more about you and less about the client.

Evaluating a client’s personal history and interpersonal behaviors is a formidable task that could easily take several sessions. Expecting that you should have a precise sense of your client’s interpersonal style after a single interview is unrealistic. A better goal is to have a few working hypotheses about your client’s interpersonal behavior patterns (see Case Example 8.2).

CASE EXAMPLE 8.2: DESCRIBING INTERPERSONAL OBSERVATIONS

The following intake note focuses on interpersonal observations and, consistent with a collaborative/therapeutic assessment model, uses a descriptive rather than a labeling approach.

Miriam, a 36-year-old White, married female, described herself as suffering from tension and stress in her marital relationship. She reported, “My husband always calls me controlling, and I hate that, but sometimes he’s right.” During our session, Miriam repeatedly (about five times) asked for more information, complaining that she “really needed” to understand exactly what counseling was about before she could be sure she wanted to proceed. As we discussed her husband’s comments in greater detail, Miriam noted that she believed her “need for control” was related to anxiety. Together we identified several triggers that elicit anxiety and are then followed by self-identified controlling behaviors. These comprised (a) new situations (like counseling), (b) her husband leaving the house without telling her his plans, and (c) when she feels neglected by her husband. Overall, these triggers may be related to an internal working model where Miriam’s sense of relational security is threatened. Consequently, one of our first therapy tasks is for Miriam to engage in a self-monitoring homework assignment to help further refine our understanding of the interpersonal triggers that activate her “controlling” behaviors.

Send Me Your Feedback and Ideas for the 7th Edition of Clinical Interviewing

And the beat goes on. . .

Rita and I are signing a contract with John Wiley & Sons to update our Clinical Interviewing text to the 7th edition. Clinical Interviewing was first published in 1993 under the title, Foundations of Therapeutic Interviewing with Allyn & Bacon publishers. As one of my academic friends once said, it was a good book, but it fell apart in the end. I was instantly worried that we hadn’t handled the final chapter very well. Turns out, he was referring to the binding.

After Allyn & Bacon let go of the copyright in 1996, we shopped the book and got great offers from Norton, Guilford, and Wiley. We went with Wiley, received excellent editorial guidance, and Clinical Interviewing was born; the text has been very popular in the graduate textbook market in psychology, counseling, and social work.

Along with the great news that we’re headed for another edition comes a rather large chunk of planning and work.

First, the planning . . .

Clinical Interviewing became popular and has remained popular because it’s a practical and accessible text that focuses on clinician competencies. We will continue that focus—we want students to not only read the text, but to return to it, keep it, and use it to remind themselves of the foundations that underlie the clinical encounter.

Another reason the book has been popular is because of the fabulous feedback and ideas we’ve gotten from people like you. We want to continue that emphasis too. If you’re familiar with Clinical Interviewing—as a professor or as a student—I’d love to hear your ideas about what we should change or add. Please, email me with any and all your ideas: john.sf@mso.umt.edu. We’ve already have some feedback, including:

  • Update the text to sync with DSM-5-TR
  • Add more content, and a video demonstration, of online (remote) interviewing (tele-mental health)
  • Add more specific content pertaining to interviewing special populations in general, and working across cultures and sexualities in particular
  • Add more (and updated) video demonstrations
  • Consider stronger and more traditional diagnostic assessment content (I’m mixed on this)

Second, the work . . .

During the past two revisions, I asked people to volunteer to read and review specific chapters. This is extra work for you, but it’s also a good academic process. Everyone who provides a chapter review will be listed in the acknowledgements. And so, if any of you would like to review a chapter (or more) and provide us with feedback and guidance for the 7th edition, please email me at john.sf@mso.umt.edu

As always, thanks for reading this and thanks for considering the opportunity to share your clinical interviewing expertise.

Helping Children Deal with Anxiety . . . and the Best Ever Children’s Anxiety Tip Sheet

Last week I got a press query to answer a few questions for an upcoming article in Parents magazine. The questions were sent to a broad spectrum of media reps and professionals. There was understandably no guarantee I would be quoted in the magazine.

No surprise, I wasn’t quoted. But my media connection was thoughtful enough to send me the article (it came out a couple days ago). IMHO commentary in the article was really good, and so I’m including a link to the article below.

Although I like the article, I have one objection. The authors immediately pathologize children’s anxiety. In the second sentence of the article, they write, “Both conditions (separation anxiety and social anxiety) are treatable with the proper diagnosis.” Using words like “conditions” and “treatable” and “diagnosis” deeply medicalizes children’s anxiety and is a bad idea. Separation anxiety and social anxiety are NOT necessarily mental disorders. It would have been better to start the article by noting that given our current global situation of uncertainty–with COVID, and other sources of angst all around us–it’s normal and natural for children to feel anxiety.

This blog post has three parts. First, I’m including a link to the article. Second, I’m including my responses to the media query. Third—and I think the best part—is a old handout I wrote for helping parents deal with children’s anxiety and fear.

Here’s the article link: https://www.parents.com/toddlers-preschoolers/how-to-help-your-kids-adjust-when-they-go-back-to-daycare-and-school-after-covid-19/

Here are my responses to the magazine’s questions:

  • What is anxiety, in a nutshell?

Anxiety is a natural human emotional response to stress, danger, or threat. One thing that makes anxiety especially distinctive and problematic is that it comes with strong physiological components. Other words used to describe anxiety states include, nervous, worried, jittery, jumpy, scared, and afraid.

Anxiety usually has a trigger or is linked to an activating situation, thought, or physical sensation. Hearing about COVID in the news or seeing someone fall ill can activate anxiety in children (and adults too!).

Anxiety is often, but not always, about the future because people tend to worry about what will happen or what is unfolding in the present. Even when children feel anxious about the past, they tend to worry about how the past will play out in the future.

  • How has COVID-19 affected children mentally? Has there been an uptick in anxiety-related conditions?

COVID-19 is a stressor or threat because of its implications (it can kill you and your loved ones) and because of how it affects children situationally. During my 30+ years as a professional psychologist, anxiety in children, teens, and adults has done nothing but increase. COVID-19 is another factor in contemporary life that has increased anxiety.

In some ways, the fact that more children are feeling anxious can be a positive thing. I know that sounds weird, but anxiety is mostly normal. A professor of mine used to say that the old saying “Misery loves company” isn’t quite true. What is true (and supported by data) is that misery loves miserable company. In other word, people feel a little better when their problems are more universal. When it comes to COVID-related anxiety, we should all recognize we’re in good company.

  • What are the symptoms of social anxiety in kids?

Social anxiety is defined as fear of being scrutinized or negatively evaluated by others. Symptoms can be physical (headaches, stomach aches, shaking, etc.), emotional (feeling scared), mental (thinking something terrible will happen), and behavioral (running away). Social anxiety is usually most intense in anticipation and during exposure to potential social evaluation. Of course, almost always, anxiety will make us imagine that everyone is staring at us—even though many other kids are also feeling anxious and as if everyone is staring at them.

  • What are the symptoms of separation anxiety in kids?

Separation anxiety occurs when children leave or part from a safe person or a safe place. Leaving the home or leaving mom or dad or grandma or grandpa will often trigger anxiety. The symptoms—because it’s anxiety—are the same as above (physical, emotional, mental, behavioral); they’re just triggered by a different situation.

  • How can you help children cope with anxiety–both in general and specific to each condition?

Children should be assured that anxiety is a message from your brain and your body. When anxiety spikes, there may be a good reason for it, just like when a fire alarm goes off and there’s really a fire and there’s physical danger and getting to a safe place is important. Children should be encouraged to identify their safe places and their safe people.

However, sometimes anxiety spikes and instead of a real fire alarm, the body and the brain are experiencing a false alarm. When there’s no immediate danger and the anxiety builds up anyway, it’s crucial for children to have a plan for how they’ll handle the anxiety. Having a plan to approach and deal with anxiety is nearly always preferable to letting the anxiety be the boss. Leaning into, facing, and embracing anxiety as a normal part of life is very important. We should all avoid taking actions designed to run away from or avoid anxiety. Developing a personal plan (along with parents, teachers, and counselors) for dealing with anxiety is the best strategy.

And, finally, here’s my tip sheet for helping with children’s anxiety

How to Help Children Deal with Fears and Anxiety

  1. Manage Your Own Anxiety and Negative Expectations: If you don’t have and display confidence in your own preparation and skills, YOUR WORRIES and negative expectations will leak into the child. Additionally, if you don’t show confidence in your child’s coping abilities, that lack of confidence will leak into them too! 
  2. Use Storytelling for Preparation and to Teach Coping Strategies: “Let’s read, Where the Wild Things Are.” Afterwards, launch into a discussion of how people deal with fears.
  3. Focus on Problem-Solving and Coping (especially as preparation): “How do you suppose people manage or get over their fears?”
  4. Instead of Dismissing Feelings, Use Soothing Empathy: “It’s no fun to be feeling so scared.”
  5. Show Gentle Curiosity:  “You seem scared.  Want to talk about it?”
  6. Provide Comforting Reassurance or Universality (after using empathy and listening with interest):  “Lots of people get afraid of things.  I remember being really afraid of dogs.”
  7. Offer Positive (Optimistic) Encouragement:  “I know it’s hard to be brave, but I know you can do it.”
  8. Have and Show Enormous Patience (connection—and holding hands—reduces anxiety):  “Yes, I’ll help you walk by Mr. Johnson’s dog again.  I think we’re both getting better at it, though.”
  9. Set Reasonable Limits:  “Even though you’re scared of monsters sometimes, you still have to be brave and go to bed.”
  10. Model how to Sit with and through Fear (No negative reinforcement!): One thing that’s always true is when fear is big, it always gets smaller, eventually. “Hey. Let’s sit here together and watch our fear go away. Let’s pay attention to what makes it get smaller.” (This might include direct coping skill work . . . or simple distraction and funny stories).
  11. Plan and Model Anxiety Management Skills: Specific skills, like deep breathing, aid with coping. Once you find some techniques or skills that are better than nothing, start to practice and rehearse using them. This can be for preparation, coping during the anxiety, or afterwards. “Let’s sit together and count our breaths. Just count one and then another. And we’ll try to find our sweet spot.”

What’s Happening with Montana Happiness?

Even a happy life cannot be without a measure of darkness, and the word happy would lose its meaning if it were not balanced by sadness. — Carl G. Jung                      

This opening quotation from Jung is a good start to a discussion of happiness. As many others have said, a “happy” life is a process and it includes the ability to embrace and experience darkness and sadness. I like the quote because it reminds us to not take happiness in the direction of toxic positivity. We don’t need that. At the same time, we need skills and attitudes to extend and prolong positive experiences and cope with our emotional challenges.

I’ve shared a bit about the Montana Happiness Project before, but it’s time for an update.

The Montana Happiness Project has four BIG initiatives.

  • Happy Schools
  • Happy Families
  • Happy Colleges
  • Happy Media

We’ve gotten started on all these initiatives, but in particular, Dylan Wright and Lillian Martz have us rolling forward on the Happy Schools initiative. This past Friday, Dylan and Lillian presented their work in Frenchtown School at the “GradCon” event at the University of Montana. They didn’t win the grand prize, but they were in the running. Their work is amazing and I’m proud to have them as a part of the Montana Happiness Project. Given their hard and smart work, it’s only a matter of time until they win some sort of grand prize. To give you a taste of their work and all that’s going on with the project, here are a couple of video clips.

A “Three Good Things” Tik Tok video produced by a high school student: https://www.youtube.com/channel/UCDXoFkQdE9ofT-WZCd7loEg

And here’s a link to the Dylan and Lillian’s presentation at GradCon. It’s under 15 minutes and will give you a great taste of the potential of integrating happiness into the lives of high school students: https://www.youtube.com/watch?v=cZvHqIMQNGg

Just in case you’re as inspired as I am, after you watch those videos, you’ll want to follow the new Montana Happiness Project YouTube site . . . and then you’ll probably want to go to Facebook where you can follow our new Facebook page: https://www.facebook.com/profile.php?id=100073966896370

Thanks, in advance, for your interest in and support of infusing happiness skills into Montana and beyond.

John SF

2/22/22: A Penchant for Redundancy: My Re-description of Four Suicide Myths

Back in the days when video recording involved film rather than digits, editors would talk about leaving excellent footage “on the floor.” How do I know this? I was alive back in the day.

Today I’ve been working on revising a continuing education “course” for ContinuingEdCourses.net. The course has been popular and so the ContinuingEdCourses.net owners asked for a revision. I stalled until they recognized my stalling for what it was essentially told me I was overdue and late, which made me decide it would feel better to finish the revision than it would to keep procrastinating. I’m guessing maybe others of you out there can relate to that particular moment in time.

While editing and revising I discovered (actually I rediscovered) my penchant for redundancy. Sometimes that penchant is intentional and other times the penchant is an annoying rediscovery. This paragraph that you’re reading in the here-and-now includes an intentional penchant. The CE course included an unintentional penchant. Are you familiar with the research on the overuse of words? If you repeat a word over and over, after only a few seconds you can become desensitized to the meaning of the word and the word will just sound like a sound. I’m feeling a penchant for that too.

Bottom line: I had to cut some nice content. It ended up on the metaphorical floor, until I picked it up, dusted it off, and put it in this blog. Here you go. . .

Editor’s note [BTW, I’m the editor here, because it’s my blog, so I own all the mistakes, misspellings, and misplaced commas]: Turns out I edited out the other redundant content, but I’m posting this anyway, because it’s still 2/22/22, which happens to be most redundant date of the year. Now, here you go. . .

Four Suicide Myths

The word “myth” has two primary meanings.:

A myth is a traditional or popular story or legend used to explain current cultural beliefs and practices. This definition emphasizes the positive guidance that myths sometimes provide. For example, the Greek myth of Narcissus warns that excessive preoccupation with one’s own beauty can become dangerous. Whether or not someone named Narcissus ever existed is irrelevant; the story tells us that too much self-love may lead to our own downfall.

The word myth is also used to describe an unfounded idea, or false notion. Typically, the false notion gets spread around and, over time, becomes a generally accepted, but inaccurate, popular belief. One contemporary example is the statement, “Lightning never strikes the same place twice.” In fact, lightning can and does strike the same place twice (or more). During an electrical storm, standing on a spot where lightning has already struck, doesn’t make for a good safety strategy.

The statement “We only use 10% of our brains” is another common myth. Although it’s likely that most of us can and should more fully engage our brains, scientific researchers (along with the Mythbusters television show) have shown that much more than 10% of our brains are active most of the time – and probably even when we’re sleeping.

False myths can stick around for much longer than they should; sometimes they stick around despite truckloads of contradictory evidence. As humans, we tend to like easy explanations, especially if we find them personally meaningful or affirming. Never mind if they’re accurate or true.

Historically, myths were passed from individuals to groups and other individuals via word of mouth. Later, print media was used to more efficiently communicate ideas, both factual and mythical. Today we have the internet and instant mythical messaging.

Suicide myths weren’t and aren’t designed to intentionally mislead; mostly (although there are some exceptions) they’re not about pushing a political agenda or selling specific products. Instead, suicide myths are the product of dedicated, well-intended people whose passion for suicide prevention sometimes outpaces their knowledge of suicide-related facts (Bryan, 2022).

Depending on your perspective, your experiences, and your knowledge base, it’s possible that my upcoming list of suicide myths will push your emotional buttons. Maybe you were taught that “suicide is 100% preventable.” Or, maybe you believe that suicidal thoughts or impulses are inherently signs of deviance or a mental disturbance. If so, as I argue against these myths, you might find yourself resisting my perspective. That’s perfectly fine. The ideas that I’m labeling as unhelpful myths have been floating around in the suicide prevention world for a long time; there’s likely emotional and motivational reasons for that. Also, I don’t expect you to immediately agree with everything in this document. However, I hope you’ll give me a chance to make the case against these myths, mostly because I believe that hanging onto them is unhelpful to suicide assessment and prevention efforts.

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

Most people assume that suicidal thoughts are about death and dying. Someone has thoughts about death, therefore, the thoughts must literally be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.

Let’s look at a parallel example. Couples who come to counseling often have conflicts about money. One partner likes to spend, while the other is serious about saving. From the surface, you might mistakenly assume that when couples have conflicts about money, the conflicts are about money – dollars, cents, spending, and saving. However, romantic relationships are complex, which is why money conflicts are usually about other issues, like love, power, and control. Nearly always there are underlying dynamics bubbling around that fuel couples’ conflicts over money.

Truth #1: Among suicidologists and psychotherapists, the consensus is clear: suicidal thoughts and impulses are less about death and more about a natural human response to intense emotional and psychological distress (aka psychache or excruciating distress). I use the term “excruciating distress” to describe the intense emotional misery that nearly always accompanies the suicidal state of mind. The take-home message from busting this myth should help you feel relief when clients mention suicide. You can feel relief because when clients trust you enough to share their suicidal thoughts and excruciating distress with you, it gives you a chance to help and support them. In contrast, when clients don’t tell you about their suicidal thoughts, then you’re not able to provide them with the services they deserve. Your holding an attitude that welcomes client openness and their sharing of distress and suicidal thoughts is foundational to effective treatment.

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

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

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

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

A recent report from the U.S. Centers for Disease Control (CDC) supports Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder (Stone et al., 2018). Keep in mind that the CDC wasn’t focusing on people who only think about or attempt suicide; their study focused only on individuals who completed suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), suffer from a mental disorder. As Wollersheim (1974) used to say, “Having the thought of suicide is not dangerous and is not the problem (p. 223).”

Truth #2: Suicidal thoughts are not – in and of themselves – a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress. The take-home message here is that clinicians should avoid judgment. I know that’s a tough message, because most of us are trained in diagnosing mental disorders and as we begin hearing of signs of depression, emotional lability, or other symptoms, it’s difficult not to begin thinking in terms of psychopathology. However, especially during initial encounters with clients who have suicidal ideation, it’s deeply important for us to avoid labeling – because if clients sense clinicians judging them, it can increase client shame and decrease the chances of them sharing openly.

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

As discussed previously, mMost suicidologists agree: that Ssuicide is extremelyvery difficult to predict (Franklin et al., 2017).

To get perspective on the magnitude of the problem, imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 13.54 of the 100,000 fans will die by suicide over the next 365 days.

A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that every one of theall 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide). Then you ask them to leave the stadium. Now you’re down to identifying which 13.54 of 15,000 will die by suicide.

For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Never mind that it would take 5,000 hours. The result: Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.

At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 13 or 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive pharmacological or psychological treatment for the remaining 7,500 people. If you choose antidepressant medications, you might inadvertently make about 200-250 of your “patients” even more suicidal. If you use psychotherapy, the time you need for effective treatment will be substantial. Either way, many of the fans will refuse treatment, including some of those who will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.

To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 13 or 14 individuals who will die by suicide over the next year. All this points to the enormity of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people some of the time.

Truth #3: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research don’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, in the vast majority of cases you won’t be able to efficiently predict or prevent suicide attempts or suicide deaths. The take-home message from busting this myth is this: Lower your expectations about accurately categorizing client risk. Most of the research suggests you’ll be wrong (Bryan, 2022; Large & Ryan, 2014). Instead, as you explore risk factors with clients, use your understanding of risk factors as a method for deepening your understanding of the individual client with whom you’re working.

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

Logical analysis implies that if psychotherapists or prevention specialists can get people to stop thinking about suicide, then suicide should be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy (Linehan, 1993; Sommers-Flanagan & Shaw, 2017)? The first reason is because most people who think about suicide never make a suicide attempt; that means you’re treating a symptom that isn’t necessarily predictive of the problem. But that’s only the tip of the iceberg.

After his son died by suicide, Rick Warren, a famous pastor and author, created a YouTube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads,

If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!

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

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

Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, sometimes we slip into try toing rationally persuadesion to encourage individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called “psychological reactance” helps explain why rational persuasion – even when well-intended – rarely makes for an effective intervention (Brehm & Brehm, 1981).

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

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

Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective. The take-home message associated with busting this myth is that the best approaches to working with clients who are suicidal are collaborative. Instead of taking the role of an esteemed authority who knows what’s best for clients, effective counselors and psychotherapists take a step back and seek to activate their client’s expertise as collaborators onagainst the suicidal problem.

The Foreword to The 15-Minute Case Conceptualization

Jon Sperry asked if I could write the foreword for a book he and his dad wrote with Oxford University Press.

Because the truth will set me free, I should admit, I’d never written a foreword before. More truth . . . I went ahead and said “Yes” to Jon because (a) I was honored and didn’t want the opportunity to write my first foreword slip away, (b) the book was (is) cool (it’s “The 15-Minute Case Conceptualization”), and (c) Jon Sperry is one of the nicest guys on the planet.

The book arrived in my mailbox yesterday. You too, can get a copy through your favorite bookseller. For more information, here’s the link to the book on the publisher’s website: https://global.oup.com/academic/product/the-15-minute-case-conceptualization-9780197517987?cc=us&lang=en&#

And for even more information about this excellent book, my first-ever foreword is below.

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I’ve needed this book for 30 years.

Just last month (before reading this book), I was standing in front of a Zoom camera, trying to teach the basics of case conceptualization to a group of 23 master’s and doctoral students. All of my fine-grained case conceptualization wisdom was being channeled into a single visual and verbal performance.

“My left hand,” I said, “is the client’s problem.” Pausing briefly for dramatic effect, I then continued, “and my right hand is the client’s goal.”

My new-found nonverbal gestures are mostly a function of seeing myself onscreen, and therefore wanting to avoid seeing myself (and being seen by the class) as boring. To add spice to my case conceptualization gesturing. “Case conceptualization is simple,” I said. “All it is, is the path we take to help clients move from their problem state . . . toward their goal state (I finished with a flourish, by wiggling the fingers on my raised right hand).”

But boiled down truths are always partly lies. Despite my fabulous mix of the verbal and nonverbal, I was lying to my students. At the time, I had thought of it as a little white lie, all for the higher purpose of simplification. And although I still like what I said and still believe in the rough truth of my visual case conceptualization description, after reading Len and Jon Sperry’s illuminating work on case conceptualization, I better understand what I should have said.

Case conceptualization is not simple. As the Sperry’s describe in this book, case conceptualization—even when summarized well—includes multiple dimensions of human behavior along with clinician perception, judgment, and decision-making. I needed much more than a few wiggly fingers to communicate the detailed nuances of case conceptualization.

What these authors have done in this book is the gracious service that great writers do so well: They have done our homework for us. They’ve read extensively, taken notes, and gifted us with elegant summaries of dense and complex concepts. They’ve made it easy for us to understand and apply the principles and practices of case conceptualization.

What I might like best is how they transformed a bulky and inconsistent literature into simple, therapist-friendly principles. They emphasize the explanatory, tailoring, and predictive powers of case conceptualization. I’ve never organized case conceptualizations using those “powers” but doing so was like switching on a light-bulb. Of course, case conceptualizations should explain the relationships between client problems and client goals and shine a bright light along the path, but rarely do theorists or writers make this linkage so efficiently. Their second principle, “tailoring” case conceptualizations to individual and diverse clients, is an essential, idiographic, Adlerian idea. The whole idea of tailoring counters the all-too-frequent cook-book approach to case conceptualization. Tailoring breathes life into creating client-specific case conceptualizations. And of course, case conceptualizations need predictive power; Len and Jon equip us with enough foundational predictive language to improve how we evaluate our own work.

Many other examples of how elegantly the authors have done our homework are sprinkled throughout this book. Here’s another of my favorite examples.

In chapter 2, they take us (in a few succinct paragraphs) from what Theodore Millon described as eight evolutionarily-driven personality disorders to eight crisply described behavioral patterns. What I love about this is that Len and Jon’s wisdom transforms what might otherwise be viewed as a pathologizing personality disorder system into language that can be used collaboratively with clients to identify contextually maladaptive interpersonal patterns. This is a beautiful transformation because it spins psychopathology into something clients not only understand but will feel compelled to embrace. The process goes something like this:

  1. Therapist and client engage in an assessment process that touches on the client’s repeating maladaptive behavior patterns. These behavior patterns are palpably troubling and far less than optimal for the client.
  2. As all clinicians inherently know, touching upon clients’ repetitive maladaptive behavior patterns can activate client vulnerability. This is a primary challenge of all counseling and psychotherapy: How can we nudge clients toward awareness without simultaneously activating resistance? For decades, psychoanalysts managed this through cautious trial interpretations. Solution-focused therapists dealt with this by never speaking of problems. Gently coaxing ambivalent clients toward awareness and change is the whole point of motivational interviewing.
  3. When addressed in a sensitive and non-pathologizing way, deep maladaptive behavior patterns can be discussed without activating resistance or excessive emotionality. This is a critical and not often discussed part of case conceptualization. Len and Jon illuminate a path for gentle, sensitive, and collaborative case conceptualization.
  4. When clients can feel, recognize, and embrace their maladaptive behavioral patterns in the context of an accepting therapeutic relationship, insight is possible. In the tradition of Adlerian therapy, when insight happens, client interest is piqued and motivation to change spikes. Good case conceptualizations articulate problem patterns in ways that compel clients to invest in change.

I’m not surprised that Len and Jon Sperry have produced such a magnificently helpful book. If you dig into their backgrounds and conduct a case conceptualization of their personality patterns, you’ll discover they wholeheartedly embrace Alfred Adler’s work and consequently, much of what they do is all about social interest or Gemeinschaftsgefühl. Len and Jon Sperry are in the business of helping others. Reading their book has already helped me become better at teaching case conceptualization. I appreciate their work, and, no doubt, the next time I begin waving my hands in front of my Zoom camera, my students will appreciate their work too.

John Sommers-Flanagan – Missoula, MT

Banned Books, Critical Race Theory, and My Cold, Dead Hands

Book banning and book burning is an old strategy designed to control information. Stephen King—the famous author and Twitter presence (https://twitter.com/StephenKing)—recommends (I’m paraphrasing here) that everyone rush out and buy and read banned books, because they contain important knowledge.

I’ve been disappointed at efforts by state legislatures, governors, school superintendents, parents, and others who have been involved in book banning, as well as any or all of the above who have suggested that critical race theory (CRT) shouldn’t be taught in colleges and universities (it’s not really taught in any formal or in-depth way in K-12 schools, but even if it were, why not?).

CRT, books, and other sources of knowledge offer perspectives. A couple days ago, I received an email from a professor and student offering me feedback on a paragraph in our counseling theories text. From the student’s perspective, the paragraph felt anti-Semitic. I pulled up the paragraph on my computer, read it, and although I didn’t see it exactly the same way as the student, she had an important point—the passage could be taken in a negative way. I emailed the student and her professor and thanked them for the feedback, noting we’ll change that paragraph in the next edition.

One goal that Rita and I have in writing textbooks is to be inclusive, accessible, and non-racist/non-sexist. Although I’m sure we always fall short of our ultimate goal, in isolation and without feedback from others, we could never even come close to or make progress in accomplishing our inclusiveness goal. We were grateful to receive the feedback. Another goal we have is to keep learning. This experience, and many others, leads me to think that there may be no better way to learn, than to listen to the perspectives of others. Why not? Where’s the benefit in closing our ears and being defensive.

Just to be clear, I’m opposed to banning books; I’m opposed to limiting the teaching of CRT; and I’m opposed to other people trying to control information available to me and others. My best guess is that when other people try to control information, they probably fear the information. Why? I don’t know, but IMHO, putting our collective heads in the sand (this brings to mind the movie, “Don’t Look Up”) is NOT a particularly useful strategy for dealing with fears. 

I teach theories all the time. At the University of Montana, I’ve taught Theories of Counseling and Psychotherapy nearly every fall semester for many years. Rita and I have a textbook on theories of counseling and psychotherapy published by John Wiley & Sons. All the hubbub over CRT has convinced me that I need to commit myself to teaching more CRT concepts in my theories course. Like all theories, I’ll treat it like a theory we can learn from.

Last week we had a visit from a university faculty person from a state where professors are being coerced into not teaching CRT. Hearing him talk about this experience made me wonder how I’d handle it if I was told I shouldn’t teach CRT at UM. Obviously, I don’t know my exact response to that scenario, and I hope it never develops, but my best hypothesis, based on a little personal theorizing, is that I’d get fired or go to jail before I agreed to NOT teach CRT, because it’s a theory, a perspective (and not the only one), from which we should all strive to learn.

I know I’m being overly dramatic, but I strongly believe that learning from the perspectives of others is a good thing. I don’t plan on stopping. To steal (and modify) an old line from the NRA: I’ll give you my banned books and theories when you pry them from my cold, dead hands.

Just saying.

Two New Theories Homework Assignments and Links to Old Theories Resources

For the past two years I’ve been using some new theories course assignments and am sharing them here.

New Assignments

The first new homework assignment is called: Multicultural Competence, Multicultural Humility, and Me.  I use this as an early (about week 3) writing assignment for first-year, first-semester M.A. students. I like using it because it gives me a taste of their writing skills, while also introducing them to foundational multicultural content. I have been consistently impressed with the students’ sensitivity to culture and desires to be humble, lifelong learners when it comes to cultural diversity.

The second new homework assignment is for students to take the long form of my Theoretical Orientation test during week 1 and then to retake it during week 15. I have them compare their scores and declare up to three “favorite” theoretical perspectives. Like the multicultural paper, this assignment has produced very interesting (and relatively fun to read) reflections from our students.

Old Resources

If you’re new to teaching or haven’t caught my previous postings for Theories resources, below are some links to materials I’ve found useful. As I’ve said before, although it’s great if you use our Theories text (woohoo), you can also use all these materials in combination with whatever text you’re using. I’m aware of many other strong textbooks—although my bet is that ours is the leader in theories jokes and humor and is probably the most well-liked by students (but I might be biased!).

Theories Course Syllabus

Here’s a link to my most recent syllabus:

Videos

I have a previous blog with links to free videos on my Youtube site. That link is below:

Although we have an excellent theories-specific video series, you need to adopt our text to access them.

Lab Activities

If you want these, email me at john.sf@mso.umt.edu and I’ll email them to you at my earliest convenience.

Good luck in your teaching this semester. I know the challenges are big, but the process of witnessing and participating in student learning is a big positive reinforcement.

2022: The Year of The Big Truth

If 2021 was the year of the Big Lie, given humanity’s tendency to swing like a pendulum, 2022 should be the Year of the Big Truth. That sounds nice. Let’s embrace truth and facts. Let’s not embrace Kellyanne Conway’s philosophy of alternative facts. But things don’t just happen. We have to make it happen. We need to, as Jean Luc Picard (aka Patrick Stewart) used to say, “Make it so.”

I’ll start.

Below I’ve made a list about what’s mostly true and mostly indisputable about the novel coronavirus (AKA COVID-19, and its variants).

There really is a virus that was identified and labelled as COVID-19. As is often the case with complicated things, the precise origins of COVID-19 are not known, and are likely unknowable. If you go online and read of someone claiming that COVID-19 was developed in a Chinese laboratory, unless you’re reading a legitimate and documented confession from someone directly involved in creating COVID-19, you’re reading something that somebody just made up. Not knowing all the facts is difficult to live with, and in the space of uncertainty, many people will make up stories. The stories might be an effort to explain something (e.g., because I can see the horizon, the earth is flat) or it may be to intentionally deceive. We have to live with the truth that there are things we do not know, including the exact origin story of COVID-19. To avoid conspiracy theories and behave like mature adults who want to contribute to the well-being of society, we should not, in the elegant words of Dr. Cordelia Fine, make shit up.

COVID-19 and its variants are highly transmissible. Our neighbors just informed us they “have the flu.” That may or may not be the perfect truth. They may have COVID. Either way—flu or COVID—I’m keeping my distance. The COVID-19 virus is virulent, and the flu sucks. You can argue the specifics, but COVID-19 is a remarkably transmissible virus.

Upon contracting COVID-19, you may have very minimal and possibly zero COVID symptoms. Some people—even people over 80 and with significant health issues—have had no noticeable COVID symptoms at all. Maybe their test was a false positive? Or, maybe their individualized response was negligible? My father, age 95, bedridden, with a variety of heart and lung ailments, is healthier now—after having tested positive for COVID-19.  

In contrast to my father and other luckier victims of the viral vector, COVID-19 makes other people moderately ill, gets others very ill, and kills the rest. COVID-19 killed my mother and several other people I know. Recently, Rita talked with someone who had seven family members die from COVID. The hard truth is that individuals have highly variable responses to a COVID-19 infection; it’s a hard truth because Americans and other humans don’t do well with variability. We like things to be simple and predictable. On average, the vast majority of people infected by COVID are not terribly ill. On the other hand, with about 824,000 Americans dead over a 24-month period, COVID-19 may be unpredictable, but it’s also consistently lethal.

Despite famous people who famously minimized COVID-19, saying it would magically go away, it hasn’t. COVID-19 has proven itself to be very persistent. Sure, the media loves a hot crisis and COVID-19 feeds the media’s need for constant crisis, but COVID’s persistence is not simply media hype.

Although it’s good to be skeptical, the preponderance of the evidence points to the likelihood that COVID-19 death estimates are just as likely to be underestimates as overestimates. Some COVID-minimizers question the death rate estimates from COVID-19, thinking they’re inflated. But there’s also evidence they’re deflated. Other minimizers argue that many COVID-related deaths have occurred in nursing home patients who, like my mother, would have died anyway, in the next year or two. Given all the other evidence pointing to COVID-19 as a legitimate medical crisis, questioning death rate estimates and quibbling over who’s dying is mostly a method to avoid thinking about 824,000 dead Americans and 5.44 million deaths worldwide.

Whether you “believe” in the transmissibility, lethality, or death rates is up to you. We should all try to remember that personal beliefs are not facts; in “fact,” thinking our personal beliefs are facts is the root of many problems. To be intellectually honest means, at least in part, that we don’t go out looking only for evidence to support our pre-existing beliefs. If we do, that’s called confirmation bias. . . which is just fancy scientific terminology for getting good at lying to ourselves.  

Speaking of lying, to describe COVID-19 as a “mild flu” is simply untrue. Not only is the mild flu rhetoric a lie, it’s a big lie that can and does cost people their lives. If you’ve spent any time working, volunteering, or hanging out in medical settings, you can see with your own eyes that COVID-19 is having an immense, dreadful, and potentially catastrophic effect on the healthcare systems and healthcare workers around the world.  

Medical journals and medical authorities have the best information available about COVID-19. Although their information isn’t perfect, and it’s consistently changing, legitimate medical professionals still give us the best information we have. People who write medical journal articles and people with medical degrees are way smarter than most of the rest of us. If you’re REALLY SERIOUS about “researching COVID-19,” you should read medical journal articles. It’s just as easy to Google the New England Journal of Medicine, the Journal of the American Medical Association, the British Medical Journal, and other top-tier medical journals, as it is to Google fringe conspiracy theorists who make up shit from their own demented imaginations. Seriously. The Big Truth Here: You should trust physicians who have taken the Hippocratic oath over COVID-19 deniers and conspiracy theorists who’s only oath is to do whatever they can to get attention and feel more important than they really are.

COVID-19 minimizers or deniers do not have your best interests at heart. Believe them at your own risk. Or, better yet, choose to not believe them. If you’re the sort of skeptic who looks for cracks in the arguments of legitimate medical research, be sure to use equal rigor to look for cracks in the arguments of people like Candace Owens, Tucker Carlson, Marco Rubio, Ted Cruz, and Laura Schlessinger. Take a minute to contemplate who you think is more interested in your (and all Americans’) well-being. Take another minute to contemplate who you think has underlying financial motivations to deceive you. In the end, the CDC, Dr. Fauci, and the World Health Organization are better sources of useful, health-promoting information than COVID-minimizers or deniers.

I’ve written all this and just now realizing I haven’t even gotten to the issues of wearing masks and vaccinations. Obviously, there’s more to come.

Please join me in working to make 2022, The Year of the Big Truth.

Paradoxical Intention, Part II: Transformative Epiphanies

Often, I have the honor of getting a personal preview of Rita S-F’s Godblogs. I sit in a cushy chair, shut my eyes, and let her words create images in my brain. It’s not unusual for her readings to stimulate unusual thoughts. But, last week, while listening, I was taken with a particular epiphany.

She was reading about how easy (and destructive) it is to be judgmental; I can’t recall the details. In response, a voice in my head spoke gently,

“I wonder if it might help if you could try, just a little, to be even more judgmental. . .” followed by an additional internal commentary “. . . said no one ever.”

The thought—of trying to be even more judgmental—made my lips curl upward into a smile. I felt an urge to laugh. Then, naturally, I thought of Viktor Frankl.

As I wrote in my last blog (https://johnsommersflanagan.com/2021/12/06/paradoxical-intention-dont-try-this-at-home-or-maybe-dont-try-it-anywhere/), Frankl was the first person I know of who explicitly discussed paradoxical intention as working like a joke to the psyche. I’ve written about that, but I’d never felt it in my gut. This time I did actually feel it. Then, and in response to the thought of intending to be “even more judgmental,” along with the urge to laugh, I also felt a small internal push back toward acceptance.  

Paradoxical intention has two parts. First, there’s the intention. I’ve tried the intention part of paradoxical intention with myself (and used it with clients) in specific situations when physical behaviors or responses feel outside of voluntary control. One example is the twitching eye syndrome. If you have an eye that’s prone to twitching, you can try to make it twitch more or try to make it twitch when it hasn’t been twitching. That’s the intention part. The other part is for the intention to be aimed toward the opposite of your goal. In the case of listening to Rita’s blog, the thought of intending to be more judgmental was received and then produced psychological push-back. What was different than any other response I’ve ever felt about paradoxical intention was my urge to smile and laugh. I’d never felt like laughing when I tried to make a bothersome eye twitch . . . twitch more.

Later—while driving I-90 west—a place where I’m prone to feeling intermittent anger toward drivers I label in my mind as “stupid,” I did another experiment.

“I wonder,” I thought to myself, “if maybe I could try to start feeling just a little angrier toward those other drivers. Being alone in the car, I tried it out with a brief litany of profanity. In response, I felt increased anger. That wasn’t good. But within seconds, my brain started the natural push-back. I took note of my greater anger and quickly judged it as unpleasant. Then, I noticed an internal psychological push-back toward the center. I suddenly wanted the anger—which usually feels so justified in the moment—to go away. And so, I let it go.

Paradoxical intention isn’t a magic trick. Nothing in the world of human psychology is magical. Paradoxical intention operates on natural psychological dynamics. Laura and Fritz Perls would have called it an internal polarity. Behaviorists like to call it a form of overcorrection. The popular press tends to reduce it to a term I can’t help but find offensive: reverse psychology.

Although you might try paradoxical intention on your children or your friends, because of one central underlying principle, that’s not a great idea. The underlying principle is best expressed by an old (and bad) joke.

“How many mental health professionals does it take to change a light bulb?”

“Only one. But the light bulb has to want to change.”

You could try a little paradoxical intention . . . on yourself . . . but only if you want to experience a new transformative epiphany.