Category Archives: Writing

Cool Counseling, Suicide Assessment and Intervention, Writing

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

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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.

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

The Foreword to The 15-Minute Case Conceptualization

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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.

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

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

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

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

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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.

Counseling and Psychotherapy Theory and Practice, Writing

Two New Theories Homework Assignments and Links to Old Theories Resources

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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.

multicultural-paper-instructionsDownload

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.

theoretical-orientation-paper-instructionsDownload
theoretical-orientation-test-long-version-revDownload

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:

coun-511-theories-2021-syllabusDownload

Videos

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

Free Video Links for Online Teaching

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.

Personal Reflections, Writing

2022: The Year of The Big Truth

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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.

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Paradoxical Intention, Part II: Transformative Epiphanies

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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.

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Writing

Paradoxical Intention: Don’t Try This at Home (or maybe don’t try it anywhere)

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People want change.

People don’t want change.

As W. R. Miller noted in his treatise on motivational interviewing (MI), ambivalence is nearly always the order of the day. Most people, most of the time, would like to be better and healthier versions of themselves. And, most people, most of the time, resist becoming better and healthier versions of themselves.  Who knew?

Alfred Adler may have been the first modern psychotherapist to write from a non-psychoanalytic perspective about how to work with individuals not interested in changing. What follows is a complex quote from Adler. He’s writing about how to work with a patient who is depressed, but not motivated or willing to change. You may need to read this excerpt several times to track it and appreciate Adler’s method. You may see all those words below and not want to put in the effort. That’s okay. You can stop reading now if you don’t want to gather in the nuance sprinkled into Adler’s indirect suggestion.

After establishing a sympathetic relation, I give suggestions for a change of conduct in two stages. In the first stage my suggestion is “Only do what is agreeable to you.” The patient usually answers, “Nothing is agreeable.” “Then at least,” I respond, “do not exert yourself to do what is disagreeable.” The patient, who has usually been exhorted to do various uncongenial things to remedy this condition, finds a rather flattering novelty in my advice, and may improve in behavior. Later I insinuate the second rule of conduct, saying that “It is much more difficult and I do not know if you can follow it.” After saying this I am silent, and look doubtfully at the patient. In this way I excite his [her/their] curiosity and ensure his attention, and then proceed, “If you could follow this second rule you would be cured in fourteen days. It is—to consider from time to time how you can give another person pleasure. It would very soon enable you to sleep and would chase away all your sad thoughts. You would feel yourself to be useful and worthwhile.”

I receive various replies to my suggestion, but every patient thinks it is too difficult to act upon. If the answer is, “How can I give pleasure to others when I have none myself?” I relieve the prospect by saying, “Then you will need four weeks.” The more transparent response, “Who gives me pleasure?” I counter with what is probably the strongest move in the game, by saying, “Perhaps you had better train yourself a little thus: do not actually do anything to please anyone else, but just think about how you could do it!” (Adler, 1964a, pp. 25–26)

Similar to Adler, Viktor Frankl also wrote about using “anti-suggestion” or paradox. Frankl was keen on this method as a means for treating anxiety, compulsions, and physical symptoms. An excerpt from our theories textbook describing Frankl’s paradoxical intention follows.

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Paradoxical Intention

. . . In a case example, Frankl discussed using paradox with a bookkeeper who was suffering from chronic writer’s cramp. The man had seen many physicians without improvement; he was in danger of losing his job. Frankl’s approach was to instruct the man to:

Do just the opposite from what he usually had done; namely, instead of trying to write as neatly and legibly as possible, to write with the worst possible scrawl. He was advised to say to himself, “now I will show people what a good scribbler I am!” And at that moment in which he deliberately tried to scribble, he was unable to do so. “I tried to scrawl but simply could not do it,” he said the next day. Within forty-eight hours the patient was in this way freed from his writer’s cramp, and remained free for the observation period after he had been treated. He is a happy man again and fully able to work. (Frankl, 1967, p. 4)

Frankl attributed the success of paradox, in part, to humor. He claimed that paradox allows individuals to place distance between themselves and their situation. New (humorous) perspectives allow clients to let go of symptoms. Frankl considered paradoxically facilitated attitude changes to represent deep and not superficial change.

Given that Frankl emphasized humor as the therapeutic mechanism underlying paradoxical intention, it fits that he would use a joke to explain how paradoxical intention works,

The basic mechanism underlying the technique…perhaps can best be illustrated by a joke which was told to me some years ago: A boy who came to school late excused himself to the teacher on the grounds that the icy streets were so slippery that whenever he moved one step forward he slipped two steps back again. Thereupon the teacher retorted, “Now I have caught you in a lie—if this were true, how did you ever get to school?” Whereupon the boy calmly replied, “I finally turned around and went home!” (Frankl, 1967, pp. 4–5)

Frankl believed paradoxical intention was especially effective for anxiety, compulsions, and physical symptoms. He reported on numerous cases, similar to the man with writer’s cramp, in which a nearly instantaneous cure resulted from the intervention. In addition to ascribing the cure to humor and distancing from the symptom, Frankl emphasized that paradox teaches clients to intentionally exaggerate, rather than avoid, their existential realities.

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I’m writing about paradoxical intention today because of an inspiration from Rita’s blog yesterday. There’s so much ostensible hate, judgment, and certainty in contemporary discourse. That got me thinking about whether a paradoxical approach might be timely and effective. Yesterday, I tried it on myself. Stay tuned, in my next post, I’ll write about how a little paradox worked out for me, and how it might help shift some of the lamentable, polarized arguments happening all around us.  

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

The Feminist Lab in Counseling and Psychotherapy Theories

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Sometimes when I’m talking about feminism in my theories class, I refer to it as the F-word. I feel like I have to do more “selling” of feminist therapy than any other approach. Maybe I’m just imagining it, but I hear rumors like, “I hope we get to skip feminist therapy in the lab” and “How do you practice feminist therapy?”

The answers are: “No, you don’t get to skip feminist therapy” and “Because feminist therapy is technically eclectic, you can practice it nearly any which way you like.” Freedom is another F-word, and there’s plenty of that when you’re being afeminist.

Yesterday, while facilitating a grad lab where the practicing happens, it was fascinating to observe feminist therapy in 10 minute snippets. I heard a beautiful self-disclosure. I heard talk of clothes and bodies and of the wish to be taken seriously. No one mentioned the patriarchy . . . but everyone . . . hopefully . . . got to taste and talk about oppression and hierarchy and the wish to be a free and expansive self.

Someone even talked about farting. Someone else about dancing. Others about uninhibited delight.

Should you be interested in what prompted these interactions, I’m attaching my feminist lab instructions here:

ch-10-lab-exploring-and-practicing-feminist-therapyDownload

Happiness, Research, Writing

Research is Hard: Procrastination is Easy

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Before and after a quick trip to NYC (see the photo), I’m teaching the research class in our Department of Counseling this year. This leads me to re-affirm a conclusion I reached long ago: Research is hard.

Research is hard for many reasons, not the least of which is that scientific language can look and feel opaque. If you don’t know the terminology, it’s easy to miss the point. Even worse, it’s easy to dismiss the point, just because the language feels different. I do that all the time. When I come upon terminology that I don’t recognize, one of my common responses is to be annoyed at the jargon and consequently dismiss the content. As my sister Peggy might have said, that’s like “throwing the baby out with the bathtub.”  

Teaching research to Master’s students who want to practice counseling and see research as a bothersome requirement is especially hard. It doesn’t help that my mastery of research design and statistics and qualitative methods is limited. Nevertheless, I’ve thrown myself into the teaching of research this semester; that’s a good thing, because it means I’m learning.

This week I shared a series of audio recordings of a woman bereaved by the suicide of her former husband. The content and affect in the recordings are incredible. Together, we all listened to the woman’s voice, intermittently cracking with pain and grief. We listened to each excerpt twice, pulling out meaning units and then building a theory around our observations and the content. More on the results from that in another blog.

During the class before, I got several volunteers, hypnotized them, and then used a single-case design to evaluate whether my hypnotic interventions improved or adversely affected their physical performance on a coin-tossing task. The results? Sort of and maybe. Before that, I gave them fake math quizzes (to evaluate math anxiety). I also used graphology and palmistry to conduct personality assessments and make behavioral and life predictions. I had written the names of four (out of 24 students) who would volunteer for the graphology and palmistry activities, placed them in an envelope, and got ¾ correct. Am I psychic? Nope. But I do know the basic rule of behavioral prediction: The best predictor of future behavior is past behavior.

Today is Friday, which means I don’t have many appointments, which means I’m working on some long overdue research reports. Two different happiness projects are burning a hole in my metaphorical research pocket. The first is a write-up of a short 2.5-hour happiness workshop on counseling students’ health and wellness. As it turns out, compared with the control group, students who completed the happiness workshop immediately and significantly had lower scores on the Center for Epidemiologic Studies Depression scale (p = .006). Even better, after 6-months, up to 81% of the participants believed they were still experiencing benefits from the workshop on at least one outcome variable (i.e., mindfulness). The point of writing this up is to emphasize that even brief workshops on evidence-based happiness interventions can have lasting positive effects on graduate students in counseling.

Given that I’m on the cusp of writing up these workshop results, along with a second study of the outcomes of a semester-long happiness course, I’m stopping here so I can get back to work. Not surprisingly, as I mentioned in the beginning of this blog, research is hard; that means it’s much easier for me to write this blog than it is to force myself to do the work I need to do to get these studies published.

As my sister Peggy used to say, I need to stop procrastinating and “put my shoulder to the grindstone.”

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Research, Therapy with Adolescents, Writing

The Efficacy of Antidepressant Medications with Youth: Part II

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After posting (last Thursday) our 1996 article on the efficacy of antidepressant medications for treating depression in youth, several people have asked if I have updated information. Well, yes, but because I’m old, even my updated research review is old. However, IMHO, it’s still VERY informative.

In 2008, the editor of the Journal of Contemporary Psychotherapy, invited Rita and I to publish an updated review on medication efficacy. Rita opted out, and so I recruited Duncan Campbell, a professor of psychology at the University of Montana, to join me.

Duncan and I discovered some parallels and some differences from our 1996 article. The parallels included the tendency for researchers to do whatever they could to demonstrate medication efficacy. That’s not surprising, because much of the antidepressant medication research is funded by pharmaceutical companies. Another parallel was the tendency for researchers to overstate or misstate or twist some of their conclusions in favor of antidepressants. Here’s the abstract:

Abstract

This article reviews existing research pertaining to antidepressant medications, psychotherapy, and their combined efficacy in the treatment of clinical depression in youth. Based on this review, we recommend that youth depression and its treatment can be readily understood from a social-psycho-bio model. We maintain that this model presents an alternative conceptualization to the dominant biopsychosocial model, which implies the primacy of biological contributors. Further, our review indicates that psychotherapy should be the frontline treatment for youth with depression and that little scientific evidence suggests that combined psychotherapy and medication treatment is more effective than psychotherapy alone. Due primarily to safety issues, selective serotonin reuptake inhibitors should be initiated only in conjunction with psychotherapy and/or supportive monitoring.

The main difference from our 1996 review was that in the late 1990s and early 2000s, there were several SSRI studies where SSRIs were reported as more efficacious than placebo. Overall, we found 6 of 10 reporting efficacy. An excerpt follows:

Our PsychInfo and PubMed database searches and cross- referencing strategies identified 10 published RCTs of SSRI efficacy. In total, these studies compared 1,223 SSRI treated patients to a similar number of placebo controls. Using the researchers’ own efficacy criteria, six studies returned significant results favoring SSRIs over placebo. These included 3 of 4 fluoxetine studies (Emslie et al. 1997, 2002; Simeon et al. 1990; The TADS Team 2004), 1 of 3 paroxetine studies (Berard et al. 2006; Emslie et al. 2006; Keller 2001), 1 of 1 sertraline study (Wagner et al. 2003), and 1 of 1 citalopram study (Wagner et al. 2004).

Despite these pharmaceutical-funded positive outcomes, medication-related side-effects were startling, and the methodological chicanery discouraging. Here’s an excerpt where we take a deep dive into the medication-related side effects and adverse events (N.B., the researchers should be lauded for their honest reporting of these numbers, but not for their “safe and effective” conclusions).

SSRI-related medication safety issues for young patients, in particular, deserve special scrutiny and articulation. For example, Emslie et al. (1997) published the first RCT to claim that fluoxetine is safe and efficacious for treating youth depression. Further inspection, however, uncovers not only methodological problems (such as the fact that psychiatrist ratings provided the sole outcome variable and the possibility that intent-to-treat analyses conferred an advantage for fluoxetine due to a 46% discontinuation rate in the placebo condition), but also, three (6.25%) fluoxetine patients developed manic symptoms, a finding that, when extrapolated, suggests the possibility of 6,250 mania conversions for every 100,000 treated youth.

Similarly, in the much-heralded Treatment of Adolescents with Depression Study (TADS), self-harming and suicidal adverse events occurred among 12% of fluoxetine treated youth and only 5% of Cognitive Behavioral Therapy (CBT) patients. Additionally, psychiatric adverse events were reported for 21% of fluoxetine patients and 1% of CBT patients (March et al. 2006; The TADS Team 2004, 2007). Keller et al. (2001), authors of the only positive paroxetine study, reported similar data regarding SSRI safety. In Keller et al.’s sample, 12% of paroxetine-treated adolescents experienced at least one adverse event, and 6% manifested increased suicidal ideation or behavior. Interestingly, in the TCA and placebo comparison groups, no participants evinced increased suicidality. Nonetheless, Keller et al. claimed paroxetine was safe and effective.

When it came to combination treatment, we found only two studies, one of which made a final recommendation that was nearly the opposite of their findings:

Other than TADS, only one other RCT has evaluated combination SSRI and psychotherapy treatment for youth with depression. Specifically, Melvin et al. (2006) directly compared sertraline, CBT, and their combination. They observed partial remission among 71% of CBT patients, 33% of sertraline patients, and 47% of patients receiving combined treatment. Consistent with previously reviewed research, Sertraline patients evidenced significantly more adverse events and side effects. Surprisingly and in contradiction with their own data, Melvin et al. recommended CBT and sertraline with equal strength.

As I summarize the content from our article, I’m aware that you might conclude that I’m completely against antidepressant medication use. That’s not the case. For me, the take-home points include, (a) SSRI antidepressants appear to be effective for some young people with depression, and (b) at the same time, as a general treatment, the risk of side effects, adverse effects, and minimal treatment effects make SSRIs a bad bet for uniformly positive outcomes, but that doesn’t mean there won’t be any positive outcomes. In the end, for my money—and for the safety of children and adolescents—I’d go with counseling/psychotherapy or exercise as primary treatments for depressive symptoms in youth, both of which have comparable outcomes to SSRIs, with much less risk.

And here’s a link to the whole article:

psychotherapy-or-meds-for-youthDownload