Sweet Home Alabama — Suicide Workshop Handouts

See below for links to the handouts for the Alabama Counseling Association workshop on 8/21/20, titled, “Suicide Assessment and Treatment Planning: A Strength-Based Approach.” Although I wish I could be there in-person in Alabama, instead, we’ll get an exciting, live, and interactive Zoom workshop!

Powerpoint Slides are Here: Suicide Workshop Alabama

Extra Handouts are Here: Alabama Handouts 8 21 20

Guidelines for Giving and Receiving Feedback

Feedback 2

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Talking with Clients who are Suicidal about Gun Safety

300px-Handgun_collection

The following is an excerpt from a section we’re developing in our strength-based suicide assessment and treatment book. Check it out and provide feedback if you like.

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Lethal Means Restriction (Safety)

Firearm availability or easy access to other lethal means is significantly linked to death by suicide (Bryan & Rudd, 2018). Access to lethal means is especially important because acute suicidal crises tend to be brief. If guns, razor blades, pills or other means are not immediately accessible, the crisis may pass without an attempt occurring. Summarizing pertinent research (Simon et al., 2001), Bryan and Rudd noted:

The final decision regarding the suicide attempt method typically occurs approximately 2 hours prior to the attempt, the final decision regarding the location of the attempt typically occurs approximately 30 minutes prior to the attempt, and the final decision to act typically occurs approximately 5 minutes prior to the attempt (p. 143).

Given that intense suicidal impulses usually pass quickly, limiting easy access to lethal means may be one of the most effective interventions available.

Bryan and colleagues (2011) published an article on how to engage clients who are suicidal in “means-restriction counseling.” As they noted, mental health professionals are expected to talk with clients about locking up and removing lethal means for suicide. However, little practical advice on how to do so is available (other than articles by Britton et al., 2016 & Bryan et al., 2011).

Early in her session with her counselor, 15-year-old Sophia (chapter 4), made it clear that she knew where her father kept the family’s guns. Although the counselor didn’t feel the need to immediately respond to her statement, as they worked on a collaborative safety plan later in the session, lethal means restriction came up for discussion:

Counselor: Sophia, we need to talk about a big issue that’s related to your safety. Is it okay with you if I just bring it up right now?

Sophia: Yeah.

Counselor: When people are suicidal, guns are the most dangerous thing to have in the house. Because my biggest goal is to keep you safe, we need to talk about how to lock up the guns or get them out of the house.

Sophia: My dad will completely freak about that.

Counselor: That’s okay. Lots of people have strong feelings about keeping guns in their homes. Don’t worry about talking with your dad, because I can do that. I want to keep you safe, but also respect your dad’s rights.

Sophia: Yeah. No way am I bringing that up.

Sophia’s reluctance to bring up gun safety with her father is natural. Her clear statement, “No way am I bringing that up,” means that bringing up gun safety is the counselor’s responsibility—as it should be.

Although phone conversations about gun safety with parents or family members may be helpful, we prefer a face-to-face contact when possible. In our experience, the best approach is to be direct, straightforward, and matter of fact. The core message is that because often suicidal impulses briefly escalate but then subside, all highly lethal methods should be locked away or removed.

Bryan and colleagues (2011) recommended presenting options for restricting firearms access. They presented options such as completely removing the means from the home by disposing of it or giving it to a supportive person. They noted you can also have clients lock up the means and give the key to a supportive person, or dismantle the firearm and give a critical piece to a supportive person (Bryan et al., 2011, pp. 341-342).

Discussing firearms during counseling sessions can result in instant escalation and polarization. Preparation helps. We recommend the following:

  • Be prepared talk about firearm safety. Talking directly about firearm safety is one of the most effective methods you have for reducing risk.
  • Keep a laser-focus on safety; avoid using the word “restriction.” Your discussion isn’t about restrictions on firearms or gun rights. Your discussion is about safety.
  • If it feels helpful, say, “I support your second amendment rights.” Conversations about firearms in the context of suicide prevention don’t need to be political.
  • As needed, state unequivocally, “I want to respect your right to own your guns . . . AND I want you (or your daughter) to be safe and to live a long and fulfilling life.”
  • Brainstorm different methods for enhancing safety. Recognize that there are two general approaches to gun safety: (a) removing firearms from the premises and (b) creating obstacles to impulsive use of firearms during a suicidal crisis (e.g., trigger locks, gun safes). Although removing guns is the safest alternative, creating obstacles is a reasonable alternative. You may want to conduct your brainstorming with the parent, client, essential support person, or all of the above.
  • Remember that because there’s no single perfect safety solution and because nearly everyone is more agreeable if they participate in a decision-making process, less directive procedures like Socratic questioning and motivational interviewing may be preferable.

If you’d rather not be boldly direct about gun safety, consider using Socratic questions to help clients come to their own conclusions. Bryan and Rudd (2018) recommend questions such as, “What do you think about someone having access to guns when they’re really upset and are suicidal?” “What might be some benefits of temporarily limiting your access to firearms?” “If complete removal of the guns is not possible, what are some other options for practicing good gun safety while you’re going through this treatment?” “What do you think about putting together a plan for this?” (p. 148).

Motivational interviewing (MI) is another less-directive method for discussing firearms safety. Keeping in mind the core principle of MI—that clients should be the ones making the case for change—clinicians can use open-ended questions, reflections, affirmation, and other technical strategies to increase firearms safety (Miller & Rollnick, 2013). The following short exchange is excerpted from an extended case example where a veteran has refused to remove his firearms, and so clinician is using MI to elicit talk around adding obstacles to enhance safety (see Britton et al., 2016, pp. 56-58, for the full case example).

**To be continued**

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

100 Days: What Happens Next?

Elephants

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

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

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

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

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

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

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

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

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

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

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

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

Trump on Ramp

What’s Wrong with Suicide Assessment?

Rainbow 2020

I’ve been contemplating whether anyone likes to go for medical examinations. I’m thinking of colonoscopies, dental exams, mammograms, stress tests, blood draws, and other more or less routine examinations of physical functioning. I’m guessing most people don’t like these procedures much, even though medical examinations  provide important information and can contribute to our good health and well-being.

Why are medical and physical assessments so darn unpleasant? One part of the unpleasantness is probably the intrusiveness. Assessments are all about gathering information; medical assessments involve gathering information about things that trigger vulnerability. Sometimes we have to be naked while we let strangers look at us and poke and prod our bodies. Even worse, medical examinations generally focus on our flaws, our weaknesses, and potential illness or disease. Whether we’re stepping on the scale in front of the medical technician or being asked, “How much alcohol do you drink?” insecurities and defensiveness can get activated. Two weeks ago when I got weighed at the doctor’s office, I wanted to complain, “Hey. That’s not right. Your scales are off. At home I weigh at least 6 pounds less than that!” What stopped me? The realization that complaining about my weight might look and sound even worse than just accepting the number. . . and so I kept quiet about my opinion. Partly–as one of my former grad students would say–we’re all about impression management.

If physical examinations trigger insecurity and vulnerability, just imagine what gets triggered in the mental and emotional domains. While at the medical office I got asked items from the PHQ-9 and GAD-7. I said “No” to every symptom, explaining, “Hey. I know all about these assessments and have written articles about them.” My med tech person wasn’t especially interested. I suspect, given her devotional attention to the computer screen, that she might not have been super-interested even if I had complained of depression or anxiety symptoms. But that’s speculation. She might have turned to me and tuned in like an empathic laser.

Nowadays, everybody is supposed to be on the alert and, if needed, ask about suicide. This idea, although theoretically great, doesn’t work all that well in reality. During a recent integrated behavioral health (IBH) training I learned of an IBH program that’s now devoting a whole three minutes to suicide assessment. Oh my. No wonder, based on a meta-analysis of 70 studies, about 60% of people who died by suicide, denied suicide ideation when asked by a general practitioner or psychiatrist (McHugh et al., 2019).

In an early version of the assessment chapter of our upcoming book on suicide assessment and treatment, I jumped headlong into the problems with suicide assessment. I figured, if answering questions about weight or alcohol consumption activate vulnerability and defensiveness, getting asked, “Have you thought about suicide?” likely stokes even greater insecurity and potentially stimulates even more evasiveness.

My early draft section on what’s wrong with suicide assessment, got substantially re-worked, maybe because some people thought I should be nicer, and maybe because I agreed with those people. However, right here on my very own blog I don’t necessarily have to be nicer. You all can tell me if I’m being too mean.

But before we get lost in my not-quite-ready-for-prime-time text below, here are my general conclusions.

1. Although questionnaires are fine for gathering information, if people are suicidal we need to rely on clinical interviews, rather than questionnaires.

2. We should ask about strengths, and not just problems (like the PHQ).

3. We should use normalizing questions (as I’ve written about before). We also need to train people how to use normalizing questions.

4. We should ask with kindness, compassion, and empathy . . . and be prepared to spend more than three minutes on the topic. We also need to train people on how to spend more than three minutes on the topic.

And finally . . . here’s the excerpt.

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Currently, in the United States, more professionals are conducting more suicide screenings and suicide assessments than ever before in the history of time. This fact begs the question: If we’re conducting more suicide screenings than ever, why are suicide rates continuing to rise? Could it be possible that suicide screenings increase suicidality?

Traditional responses to this question include:

  • We don’t know why suicide rates continue to rise despite prevention efforts
  • Asking about suicide doesn’t cause or increase suicidality.

For many years suicide researchers and practitioners have emphasized that asking about suicide doesn’t increase suicidality. Everyone in the suicidology field teaches that clinicians, paraprofessionals, and concerned non-professionals should ask directly about suicide ideation. We agree with this stance. The unanimous message is:

Clinicians should ask directly about suicide. Asking directly doesn’t increase risk or put the idea into the client’s head. Most clients either accept questions about suicide as a standard mental health practice, or feel relieved to be asked about suicide.

Despite our agreement with the philosophy of asking directly, all too often, when we’ve witnessed the question being asked, we’ve seen it asked badly. In one case, as a part of a mental status examination, we saw a social worker ask an elderly man, “Have you had thoughts about suicide?” The man responded, “I don’t know.” The social worker rephrased the question, “Do you think about death and dying?” Again, the man said, “I don’t know.” The social worker moved on. There was no follow up.

In another case, we listened as a nurse used a suicide assessment protocol during an initial interview. She asked a question from item 9 of the Patient Health Questionnaire-9 (PHQ-9): “Have you had thoughts that you would be better off dead, or of hurting yourself?” The patient said, “Yes.” Then, much to our surprise, the nurse simply asked another question. There was no empathy. There was no compassion. The nurse looked back at her clipboard, made a note, and continued asking questions from a script. Apparently the script didn’t include a box for checking off empathy or compassion.

Over the past decade we’ve repeatedly been asked to consult with schools on their suicide assessment and referral process. All too often we’ve heard from exasperated school counselors and school psychologists about how much they hate trying to interpersonally engage potentially suicidal students using a risk factor checklist or questionnaire items. School professionals complain about rigid procedures that result in referrals to the local hospital emergency department and end in ruptured therapeutic relationships.

Beyond these less-than-optimal scenarios, there’s empirical evidence indicating that suicide assessment procedures don’t always have neutral or positive effects. Harris and Goh (2017) conducted a randomized control trial evaluating the emotional effects of a suicide assessment protocol on Singapore residents. Although they reported no evidence for iatrogenic effects, 24% of participants experienced increased negative affect following administration of the Suicide Affect-Behavior-Cognition scale (Harris et al., 2015). Using a similar protocol, a Dutch research team reported similar results (de Beurs, Ghoncheh, Geraedts, & Kerkhof, 2016). After responding to 21 items from the Beck Scale for Suicide Ideation (BSSI, **), participants generally reported increased negative affect. In particular, about 15% of the BSSI group had substantially negative affective responses to the BSSI items.

We have no doubt that the social worker, the nurse, and the school districts featured in the preceding examples of poor suicide assessment were well-intended. For many reasons—including anxiety, lack of professional training, client hostility, fears of liability, or countertransference reactions—professionals often engage poorly with suicidal clients. We’re also certain that most of the time, clients view questions about suicide as necessary, and sometimes consider queries about suicide a welcome relief. However, we also believe, as in the two research examples, that repeated questioning about depression, suicide, anxiety, insomnia, and other aversive symptoms—without a skilled clinician to collaboratively explore depressive symptoms and reorient clients toward strengths and positive experiences—can activate negative affect. These reasons—and more—have convinced us that mental health and school professionals can do better than simply administering the PHQ-9, the BSSI items, and following a checklist when evaluating for suicide. Instead, professionals should balance their questioning, follow-up sensitively to clients’ responses, and validate that suicidal thoughts are a natural reaction to painful emotions and disturbing situations. All this points to the need to view suicide assessment differently; instead of adopting an authoritative assessment role, we encourage you to apply the principles of therapeutic assessment when conducting suicide assessment interviews.

Despite our critique of how suicide assessment is practiced, we strongly recommend that you follow the usual guidance, and ask directly about suicide ideation. We just want to add, you should do it right. The rest of this chapter is all about how to weave in therapeutic assessment principles so you can do suicide assessment right.

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As always, let me know what you think. I promise to be nice.

 

 

Reality Therapy: Developing Effective Plans

With Wubbolding

Thanks to Molly Molloy, the Montana Office of Rural Health, the Montana Flex Program, and the Montana Hospital Association, I had a chance to present as part of a “Rethinking Resiliency” series this morning. One question that came up had to do with how we can make better plans to facilitate our self-improvement. The best answer I could come up with was to follow Robert Wubbolding’s guidance on effective planning, from a reality therapy perspective. All of the preceding leads me to posting a section from our Counseling and Psychotherapy Theories textbook on Reality Therapy and Planning.

Here we go:

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Wubbolding (1988, 1991, 2000, 2011 . . . and pictured above) has written extensively about how reality therapists help clients develop plans for making positive life changes. Therapists help clients make positive and constructive plans. Wubbolding (1988) uses the acronym SAMI2C3 to outline the essential ingredients of an effective plan:

S = Simple: Effective plans are simple. If a plan generated in reality therapy is too complex, the client may become confused and therefore not follow through.

A = Attainable: Effective plans are attainable or realistic. If the plan is unattainable, the client can become discouraged.

M = Measurable: Effective plans are measurable. Clients need to know if the plan is working and if they’re making progress.

I = Immediate: Effective plans can be enacted immediately, or at least very soon. If clients have to wait too long to implement a plan, motivation may be compromised.

I = Involved: Helping professionals can be involved with their client’s or student’s planning. This should be done ethically and in ways that promote client independence.

C = Controlled: The planner has exclusive control over effective plans. Avoid having clients develop plans that are contingent on someone else’s behavior.

C = Committed: Clients need to commit to their plans. If a client is only half-heartedly invested in the plan, the plan is less likely to succeed.

C = Continuous: Effective plans are continuously implemented. When the process is going well, reality therapy clients have continuous awareness of what they want and of their plan for getting what they want. This high level of awareness reminds us of mindfulness or conscious-raising therapeutic techniques.

Wubbolding (1988) also recommended that individuals learning to conduct reality therapy develop a plan for themselves. He noted that to be effective reality therapists, practitioners should obtain consultation and/or supervision from certified reality therapists (in addition, we recommend that you practice living your life using choice theory rules; see Putting it in Practice 9.3).

Putting it in Practice 9.3

Living Choice Theory: The Four Big Questions

Four questions have been developed to help students and clients live the choice theory lifestyle (Wubbolding, 1988). These questions are derived from Wubbolding’s WDEP formula. During one full week, do your best to keep these four reality therapy questions on your mind:

  1. What do you want? (Wants)
  2. What are you doing? (Doing)
  3. Is it working? (Evaluation)
  4. Should you make a new plan? (Planning)

Every day you’re operating with a personal plan. The plan may or may not be any good and it may or may not be clear. The point is this: You’re thinking and doing things aimed toward getting your basic needs met. Therefore, consistently ask yourself the four preceding questions. This will help make your plan and choices more explicit.

Wubbolding’s four questions are powerful and practical. Think about how you might apply them when doing therapy with a teenager. Now think about how you might apply them as a consultant for a local business. Whether you’re consulting with a teenager or a business leader, there are hardly any other four questions that are more relevant and practical.

In the space that follows each question, answer the four questions for yourself today.

  1. What do you want? ________________________________________
  2. What are you doing? _______________________________________
  3. Is it working? _____________________________________________
  4. Should you make a new plan? _______________________________

After you’ve answered the questions, go back and think about what you’ve written as your answer for Question 1.

To Mask or Not to Mask: Making America Rational Again

Make America Rational Again

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

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

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

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

“What’s the third choice?”

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

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

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

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

Individualizing Suicide Risk Factors in the Context of a Clinical Interview

Spring 2020

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

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

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

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

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

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

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

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

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

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

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

A Strength-Based Suicide Assessment and Treatment Model

Bikes Snow 3

Over the past couple years, with feedback from workshop participants, supervisees, clients, and people with lived experiences around suicide, we’ve continued to refine our strength-based suicide assessment and treatment model. Below is a short excerpt from chapter 1 of our upcoming book. This excerpt gives you a glimpse at the strength-based model.

Seven Dimensions of Being Human: Where Does It Hurt and How Can I Help?

We began this chapter describing the case of Alina. Mostly likely, what you remember about Alina is that she displayed several frightening suicide risk factors and openly shared her suicidal thoughts. However, Alina is not just a suicidal person—she’s a unique individual who also exhibited a delightful array of idiosyncratic quirks, problems, and strengths. Even her reasons for considering suicide are unique to her.

When working with suicidal clients or students, it’s easy to over-focus on suicidality. Suicide is such a huge issue that it overshadows nearly everything else and consumes your attention. Nevertheless, all clients—suicidal or not—are richly complex and have a fascinating mix of strengths and weaknesses that deserve attention. To help keep practitioners focused on the whole person—and not just on weaknesses or pathology—we’ve developed a seven-dimension model for understanding suicidal clients.

Suicide Treatment Models

In the book, Brief cognitive-behavioral therapy for suicide prevention, Bryan and Rudd (2018) describe three distinct models for working with suicidal clients. The risk factor model emphasizes correlates and predictors of suicidal ideation and behavior. Practitioners following the risk factor model aim their treatments toward reducing known risk factors and increasing protective factors. Unfortunately, a dizzying array of risk factors exist, some are relatively unchangeable, and in a large, 50-year, meta-analytic study, the authors concluded that risk factors, protective factors, and warning signs are largely inaccurate and not useful (Franklin et al., 2017). Consequently, treatments based on the risk factor model are not in favor.

The psychiatric model focuses on treating psychiatric illnesses to reduce or prevent suicidality. The presumption is that clients experiencing suicidality should be treated for the symptoms linked to their diagnosis. Clients with depression should be treated for depression; clients diagnosed with post-traumatic stress disorder should be treated for trauma; and so on. Bryan and Rudd (2018) note that “accumulating evidence has failed to support the effectiveness of this conceptual framework” (p. 4).

The third model is the functional model. Bryan and Rudd (2018) wrote: “According to this model, suicidal thoughts and behaviors are conceptualized as the outcome of underlying psychopathological processes that specifically precipitate and maintain suicidal thoughts and behaviors over time” (p. 4). The functional model targets suicidal thoughts and behaviors within the context of the individual’s history and present circumstances. Bryan and Rudd (2018) emphasize that the superiority of the functional model is “well established” (p. 5-6).

Our approach differs from the functional model in several ways. Due to our wellness and strength-based orientation, we studiously avoid presuming that suicidality is a “psychopathological process.” Consistent with social constructionist philosophy, we believe that locating psychopathological processes within clients, risks exacerbation and perpetuation of the psychopathology as an internalized phenomenon (Hansen, 2015; Lyddon, 1995). In addition to our wellness, strength-based, social constructionist foundation, we rely on an integration of robust suicide theory (we rely on works from Shneidman, Joiner, Klonsky & May, Linehan, and O’Connor). We also embrace parts of the functional model, especially the emphasis on individualized contextual factors. Overall, our goal is to provide counseling practitioners with a practical and strength-based model for working effectively with suicidal clients and students.

The Seven Dimensions

Thinking about clients using the seven life dimensions can organize and guide your assessment and treatment planning. Many authorities in many disciplines have articulated life dimensions. Some argue for three, others for five, seven, or even nine dimensions. We settled on seven that we believe reflect common sense, science, philosophy, and convenience. Each dimension is multifaceted, overlapping, dynamic, and interactive. Each dimension includes at least three underlying factors that have theoretical and empirical support as drivers of suicide ideation or behavior. The dimensions and their underlying factors are in Table 1.1.

Insert Table 1.1 About Here

Table 1.1: Brief Descriptions of the Seven Dimensions

  • The Emotional Dimension consists of all human emotions ranging from sadness to joy. Empirically supported suicide-related problems in the emotional dimension include:
    • Excruciating emotional distress
    • Specific disturbing emotions (i.e., guilt, shame, anger, or sadness)
    • Emotional dysregulation
  • The Cognitive Dimension consists of all forms of human thought. Empirically supported suicide-related problems in the cognitive dimension include:
    • Hopelessness
    • Problem-solving impairments
    • Maladaptive thoughts
    • Negative core beliefs and self-hatred
  • The Interpersonal Dimension consists of all human relationships. Empirically supported suicide-related problems in the interpersonal dimension include:
    • Social disconnection, alienation, and perceived burdensomeness
    • Interpersonal loss and grief
    • Social skill deficits
    • Repeating dysfunctional relationship patterns
  • The Physical Dimension consists of all human biogenetics and physiology. Empirically supported suicide-related problems in the physical dimension include:
    • Biogenetic predispositions and illness
    • Sedentary lifestyle (lack of movement)
    • Agitation, arousal, anxiety
    • Trauma, nightmares, insomnia
  • The Spiritual-Cultural Dimension consists of all religious, spiritual, or cultural values that provide meaning and purpose in life. Empirically supported suicide-related problems in the spiritual-cultural dimension include:
    • Religious or spiritual disconnection
    • Cultural disconnection or dislocation
    • Meaninglessness
  • The Behavioral Dimension consists of human action and activity. Empirically supported suicide-related problems in the behavioral dimension include:
    • Using substances or cutting for desensitization
    • Suicide planning, intent, and preparation
    • Impulsivity
  • The Contextual Dimension consists of all factors outside of the individual that influence human behavior. Empirically supported suicide-related problems in the contextual dimension include:
    • No connection to place or nature
    • Chronic exposure to unhealthy environmental conditions
    • Socioeconomic oppression or resource scarcity (e.g., Poverty)

End of Table 1.1

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This past week Rita and I submitted the final draft manuscript to the publisher. The next step is a peer review process. While the manuscript is out for review, there’s still time to make changes and so, as usual, please email me with feedback or post your thoughts here.

Thanks for reading!

John S-F

The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.