Now that I’m immersed in positivity every day as the Director of the Center for the Advancement of Positive Education, I think I’ve become weirder.
Some of you, including my sisters and brothers-in-law may be wondering, “Wait. How could John become any MORE weird than he already is?”
You know what they say: “All things are possible!” [Actually, I don’t know why I just wrote all things are possible, because, even in my most positive mental states, I don’t believe that BS. All things are not possible. I could make a list of impossible things, but I’ve already digressed.]
Here’s what I mean by me becoming even weirder.
I find myself more easily hearing and seeing the pervasive negative narratives emerging around us. I could make another long list of all the bad ideas (negative narratives) I’m noticing (think: “fight or flight”), but I’ll limit myself to one example: The “Trigger warning.”
Trigger warnings are statements that alert listeners or viewers (or people attending my suicide assessment workshops) to upcoming intense and potentially emotionally activating content. Over the past 10ish years, we’ve all started giving and receiving trigger warnings from time to time, now and then. A specific example, “The next segment of this broadcast includes gunfire” or “In my lecture I will be talking about mental health and suicide.”
As a college professor in a mental health-related discipline, I became well-versed in providing trigger warnings. . . and have offered them freely. Because some people have strong and negative emotional reactions to specific content, providing trigger warnings has always made good sense. The point is to alert people to intense content so they can take better care of themselves or opt out (stop listening/viewing). Trigger warnings are important and, no doubt, useful for helping some people prepare for emotionally activating content.
As a college professor, I’m also obligated to keep up with the latest research. Unfortunately, the research on trigger warnings isn’t very supportive of trigger warnings. Argh! In general, it appears that trigger warnings sensitize people and might make some people more likely to have a negative emotional response. You can read a 2024 meta-analysis on trigger warning research here: https://journals.sagepub.com/doi/10.1177/21677026231186625
In response to the potential adverse effects of trigger warnings, I came up with a clever idea: I started giving trigger warnings for my trigger warnings. These were something like, “Because research suggests that trigger warnings can make you more reactive to negative content, I want to give you a trigger warning for my trigger warning and encourage you to not let my warning make you more sensitive than you already would be.”
Then, about a year ago, I had an epiphany. [I feel compelled to warn you that my epiphany might just be common sense, but it felt epiphany-like to me]
I realized—perhaps aided by my experiences training to do hypnosis—that trigger warnings might be functioning as negative suggestions, implying that people might not be able to handle the content and priming them to notice and focus on their negative reactions.
Given my epiphany, I was energized—as the solution-focused people like to say—to do something different. The different thing I settled on was to invent “The Strength Warning.”
[Here’s where I digress again to pitch a podcast. Paula Fontenelle, an all-around wonderful, kind, and competent professional, has a new podcast called, Relating to AI. And, lucky me, I got to be one of her very first guests. And, lucky Paula (joking now), she got to have me start her podcast interview by explaining and demonstrating the strength warning. Consequently, if you’re interested in AI and/or in hearing me demonstrate the strength warning, the link to Paula’s podcast is here: https://www.youtube.com/watch?v=MHDIYrXw_2Y]
Although watching/listening to me give the strength warning with Paula is way more fun, I will also describe it below.
For strengths warnings, I say things like this.
In addition to warning you about sensitive content coming up, I also want to give you a Strength Warning. A strength warning is mostly the opposite of a trigger warning. I want you to watch out for the possibility that being here together in this lecture and with your colleagues might just make you notice yourself feeling stronger, feeling better, feeling more prepared, feeling more knowledgeable, and maybe even feeling smarter. So . . . watch for that, because I think you might even be stronger than you think you are.
Please, let me know what you think about my invention of the strength warning. I encourage you to try it out when you’re teaching or presenting.
I also encourage you to try out Paula’s new podcast. If you do, you might feel smarter, stronger, and more prepared to face the complicated issue of having AI intrude on our lives.
While reviewing and revising the behavior therapy chapter from our Theories textbook, I found myself revisiting my awe of Mary Cover Jones. I think too many contemporary therapists don’t know about Mary Cover Jones and don’t understand the behavioral (classical conditioning) model for understanding and treating anxiety disorders, including OCD and PTSD.
In most chapters, we include a feature called a “Brain Box.” Here’s the box from Chapter 7, Behavior Theory and Therapy.
7.1 Brain Science May be Shiny, but Exposure Therapy is Pure Gold
In honor of Joseph Wolpe, let’s start with mental imagery.
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Imagine you’ve travelled back in time to your first week of high school. You look around and see that one of your classmates is named Mary Jones.
Mary is an ordinary girl with an ordinary name. Over the years, you don’t notice her much. She seems like a nice person, a fairly good student, and someone who doesn’t get in trouble or draw attention to herself.
Four years pass. A new student joined your class during senior year. His name is Daniel Tweeter. Toward the end of the year, Daniel does a fantastic Prezi presentation about a remarkable new method for measuring reading outcomes. He includes cool video clips and boomerang Snapchat. When he bows at the end, he gets a standing ovation. Daniel is a good student and a hard worker; he partnered up with a college professor and made a big splash. Daniel deserves recognition.
However, as it turns out, over the whole four years of high school, Mary Jones was quietly working at a homeless shelter; week after week, month after month, year after year, she was teaching homeless children how to read. In fact, based on Daniel’s measure of reading outcomes, Mary had taught over 70 children to read.
Funny thing. Mary doesn’t get much attention. All everybody wants to talk about is Daniel. At graduation, he wins the outstanding graduate award. Everyone cheers.
Let’s stop the visualization and reflect on what we imagined.
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Like birds and raccoons, humans tend to like shiny things. Mary did incredible work, but hardly anyone noticed. Daniel did good work, and got a standing ovation and the top graduate award.
The “shiny-thing theory” is my best explanation for why we tend to get overly excited about brain science. It’s important, no doubt, but brain imaging isn’t therapy; it’s just a cool way to measure or validate therapy’s effects.
Beginning from at least 1924, when Mary Cover Jones was deconditioning fear out of little children, behavior therapy has shown not only great promise, but great outcomes. However, when researchers showed that exposure therapy “changes the brain,” most of the excitement and accolades were about the brain images; exposure therapy was like background noise. Obviously, the fact that exposure therapy (and other therapies) change the brain is great news. It’s great news for people who have anxiety and fear, and it’s great news for practitioners who use exposure therapy.
This is all traceable to neuroscience and human evolution. We get distracted by shiny objects and miss the point because our neural networks and perceptual processes are oriented to alert us to novel (new) environmental stimuli. This is probably because change in the form of shiny objects might signal a threat or something new and valuable. We therefore need to exercise self-discipline to focus in and not overlook that behavior therapy in general, and exposure therapy in particular, has been, is, and probably will continue to be, the most effective approach on the planet for helping people overcome anxiety and fear. In addition, you know what, it doesn’t really matter that it changes the brain (although that’s damn cool and affirming news). What matters is that it changes clients’ lives.
Exposure therapy, no matter how you package it, is highly effective for treating anxiety. This statement is true whether we’re talking about Mary Cover Jones and her evidence-based counterconditioning cookies or Francine Shapiro and eye movement desensitization reprocessing (EMDR). It’s also true whether we’re talking about virtual reality exposure, imaginal exposure, massed exposure, spaced exposure, in vivo exposure, interoceptive exposure, response prevention (in obsessive-compulsive disorder), or the type of exposure that acceptance and commitment therapists use (note that they like to say it’s “different” from traditional classical conditioning exposure, but it works, and that’s what counts).
In the end, let’s embrace and love and cheer brain imaging and neuroscience, but not forget the bottom line. The bottom line is that exposure therapy works! Exposure therapy is the genuine article. Exposure therapy is pure gold.
Mary Cover Jones is the graduate of the century; she was amazing. Because of her, exposure therapy has been pure gold for 93+ years, and now we’ve got cool pictures of the brain to prove it.
Mary Cover Jones passed away in 1987. Just minutes before her death, she said to her sister: “I am still learning about what is important in life” (as cited in Reiss, 1990).
Tomorrow’s talk is titled, Ten Things Everyone Should Know About Children’s Mental Health and Happiness. Because this talk is about what everyone should know, I suspect everyone will be there. So, I’ll see you soon.
Given the possibility that everyone won’t be there, I’m sharing the list of the 10 things, along with some spiffy commentary.
First, I’ll give a strength warning. If you don’t know what that means, you’re not alone, because I made it up. It might be the coolest idea ever, so watch for more details about it in future blogs.
Then, I’ll say something profound like, “The problems with mental health and happiness are big, and they seem to just be getting bigger.” At which point, I’ll launch into the ten things.
Mental health and happiness are wicked problems. This refers to the fact that mental health and happiness are not easy to predict, control, or influence. They’re what sociologists call “wicked problems,” meaning they’re multidimensional, non-linear, elicit emotional responses, and often when we try to address them, our well-intended efforts backfire.
Three ways your brain works. [This one thing has three parts. Woohoo.]
We naturally look for what’s wrong with us. Children and teens are especially vulnerable to this. In our contemporary world they’re getting bombarded with social media messages about diagnostic criteria for mental disorders so much that they’re overidentifying with mental disorder labels.
We find what we’re looking for. This is called confirmation bias, which I’ve blogged about before.
What we pay attention to grows. This might be one of the biggest principles in all of psychology. IMHO, we’re all too busy growing mental disorders and disturbing symptoms (who doesn’t have anxiety?).
We’re NOT GOOD at shrinking NEGATIVE behaviors. This is so obvious that my therapist friends usually say, “Duh” when I mention it.
We’re better at growing POSITIVE behaviors. Really, therapy is about helping people develop skills and strengths for dealing with their symptoms. More skills, strengths, and resources result in fewer disturbing symptoms.
Should we focus on happiness? The answer to this is NO! Too much preoccupation with our own happiness generally backfires.
What is happiness? If you’ve been following this blog, you should know the answer to this question. Just in case you’re blanking, here’s a pretty good definition: From Aristotle and others – “That place where the flowering of your greatest (and unique) virtues, gifts, skills, and talents intersect (over time) with the needs of the world [aka your family/community].”
You can flip the happiness. This thing flows from a live activity. To get it well, you’ll need to be there!
Just say “No” to toxic positivity. To describe how this works and why we say no to toxic positivity, I’ll take everyone through the three-step emotional change trick.
Automatic thoughts usually aren’t all that positive. How does this work for you? When something happens to you in your life and your brain starts commenting on it, does your brain usually give you automatic compliments and emotional support? I thought not.
How anxiety works. At this point I’ll be fully revved up and possibly out of time, so I’ll give my own anxiety-activated rant about the pathologizing, simplistic, and inaccurate qualities of that silly “fight or flight” concept.
Depending on timing, I may add a #11 (Real Mental Health!) and close with my usual song.
If you’re now experiencing intense FOMO, I don’t blame you. FOMO happens. You’ll just need to lean into it and make a plan to attend one of my future talks on what everyone should know.
Thanks for reading and have a fabulous evening. I’ll be rolling out of Absarokee on my way to Butte at about 5:30am!
All too often on this blog I’m writing about what I’m doing and I’m thinking. I suppose that’s just fine, after all, it’s my blog. But, as many people have said before me and better than I can, “Other people matter” and seeing the light (or the divine) in others is among the most meaningful experiences we can have.
One light I’ve been seeing lately is the strengths-based suicide prevention work that the Firekeeper Alliance (a non-profit org) is doing on the Blackfeet Reservation in Northern Montana. In July, they had a “suicide prevention” heavy metal concert called Fire in the Mountains, complete with amazing metal bands and equally amazing panels, discussions, and speakers. If you’re interested in creative approaches to well-being, you really should check them out.
This past Thursday, Charlie Speicher, architect of the Firekeeper Alliance and Director of the Buffalo Hide Academy in Browning, shared one of their Suicide Prevention Month activities. The idea is simple: Feature the beauty and strengths of the reservation and its people. The product: A 12-minute video that focuses on what gives the Blackfeet people hope. The video captures the faces, sentiments, and emotions in response to “What gives you hope?” Here’s the link on Youtube:
All too often, people think and share information about the challenges of reservation life. This video shares hope, beauty, and potential.
With your help, I hope this video travels far and wide. Please share. At the very least, it should get all over Montana media. And, just in case anyone has the right connections, I think it’s a great fit for virtually any national media outlet that wants to shift toward a positive narrative in Indian Country.
Thanks for reading . . . and for seeing the light (and fire) in others.
On July 24, in Helena, I attended a fun and fascinating meeting sponsored by the Carter Center. I spent the day with a group of incredibly smart people dedicated to improving mental health in Montana.
The focus was twofold. How do we promote and establish mental health parity in Montana and how do with improve behavioral health in schools? Two worthy causes. The discussions were enlightening.
We haven’t solved these problems (yet!). In the meantime, we’re cogitating on the issues we discussed, with plans to coalesce around practical strategies for making progress.
During our daylong discussions, the term evidence-based treatments bounced around. I shared with the group that as an academic psychologist/counselor, I could go deep into a rabbit-hole on terminology pertaining to treatment efficacy. Much to everyone’s relief, I exhibited a sort of superhuman inhibition and avoided taking the discussion down a hole lined with history and trivia. But now, much to everyone’s delight (I’m projecting here), I’m sharing part of my trip down that rabbit hole. If exploring the use of terms like, evidence-based, best practice, and empirically supported treatment is your jam, read on!
The following content is excerpted from our forthcoming text, Counseling and Psychotherapy Theories in Context and Practice (4th edition). Our new co-author is Bryan Cochran. I’m reading one of his chapters right now . . . which is so good that you all should read it . . . eventually. This text is most often used with first-year students in graduate programs in counseling, psychology, and social work. Consequently, this is only a modestly deep rabbit hole.
Enjoy the trip.
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What Constitutes Evidence? Efficacy, Effectiveness, and Other Research Models
We like to think that when clients or patients walk into a mental health clinic or private practice, they will be offered an intervention that has research support. This statement, as bland as it may seem, would generate substantial controversy among academics, scientists, and people on the street. One person’s evidence may or may not meet another person’s standards. For example, several popular contemporary therapy approaches have minimal research support (e.g., polyvagal theory and therapy, somatic experiencing therapy).
Subjectivity is a palpable problem in scientific research. Humans are inherently subjective; humans design the studies, construct and administer assessment instruments, and conduct the statistical analyses. Consequently, measuring treatment outcomes always includes error and subjectivity. Despite this, we support and respect the scientific method and appreciate efforts to measure (as objectively as possible) psychotherapy outcomes.
There are two primary approaches to outcomes research: (1) efficacy research and (2) effectiveness research. These terms flow from the well-known experimental design concepts of internal and external validity (Campbell et al., 1963). Efficacy research employs experimental designs that emphasize internal validity, allowing researchers to comment on causal mechanisms; effectiveness research uses experimental designs that emphasize external validity, allowing researchers to comment on generalizability of their findings.
Efficacy Research
Efficacy research involves tightly controlled experimental trials with high internal validity. Within medicine, psychology, counseling, and social work, randomized controlled trials (RCTs) are the gold standard for determining treatment efficacy. RCTs statistically compare outcomes between randomly assigned treatment and control groups. In medicine and psychiatry, the control group is usually administered an inert placebo (i.e., placebo pill). In the end, treatment is considered efficacious if the active medication relieves symptoms, on average, at a rate significantly higher than placebo. In psychotherapy research, treatment groups are compared with a waiting list, attention-placebo control group, or alternative treatment group.
To maximize researcher control over independent variables, RCTs require that participants meet specific inclusion and exclusion criteria prior to random assignment to a treatment or comparison group. This allows researchers to determine with greater certainty whether the treatment itself directly caused treatment outcomes.
In 1986, Gerald Klerman, then head of the National Institute of Mental Health, gave a keynote address to the Society for Psychotherapy Research. During his speech, he emphasized that psychotherapy should be evaluated through RCTs. He claimed:
We must come to view psychotherapy as we do aspirin. That is, each form of psychotherapy must have known ingredients, we must know what these ingredients are, they must be trainable and replicable across therapists, and they must be administered in a uniform and consistent way within a given study. (Quoted in Beutler, 2009, p. 308)
Klerman’s speech advocated for medicalizing psychotherapy. Klerman’s motivation for medicalizing psychotherapy partly reflected his awareness of heated competition for health care dollars. This is an important contextual factor. Events that ensued were an effort to place psychological interventions on par with medical interventions.
The strategy of using science to compete for health care dollars eventually coalesced into a movement within professional psychology. In 1993, Division 12 (the Society of Clinical Psychology) of the American Psychological Association (APA) formed a “Task Force on Promotion and Dissemination of Psychological Procedures.” This task force published an initial set of empirically validated treatments. To be considered empirically validated, treatments were required to be (a) manualized and (b) shown to be superior to a placebo or other treatment, or equivalent to an already established treatment in at least two “good” group design studies or in a series of single case design experiments conducted by different investigators (Chambless et al., 1998).
Division 12’s empirically validated treatments were instantly controversial. Critics protested that the process favored behavioral and cognitive behavioral treatments. Others complained that manualized treatment protocols destroyed authentic psychotherapy (Silverman, 1996). In response, Division 12 held to their procedures for identifying efficacious treatments but changed the name from empirically validated treatments to empirically supported treatments (ESTs).
Advocates of ESTs don’t view common factors in psychotherapy as “important” (Baker & McFall, 2014, p. 483). They view psychological interventions as medical procedures implemented by trained professionals. However, other researchers and practitioners complain that efficacy research outcomes do not translate well (aka generalize) to real-world clinical settings (Hoertel et al., 2021; Philips & Falkenström, 2021).
Effectiveness Research
Sternberg, Roediger, and Halpern (2007) described effectiveness studies:
An effectiveness study is one that considers the outcome of psychological treatment, as it is delivered in real-world settings. Effectiveness studies can be methodologically rigorous …, but they do not include random assignment to treatment conditions or placebo control groups. (p. 208)
Effectiveness research focuses on collecting data with external validity. This usually involves “real-world” settings. Effectiveness research can be scientifically rigorous but doesn’t involve random assignment to treatment and control conditions. Inclusion and exclusion criteria for clients to participate are less rigid and more like actual clinical practice, where clients come to therapy with a mix of different symptoms or diagnoses. Effectiveness research is sometimes referred to as “real world designs” or “pragmatic RCTs” (Remskar et al., 2024). Effectiveness research evaluates counseling and psychotherapy as practiced in the real world.
Other Research Models
Other research models also inform researchers and practitioners about therapy process and outcome. These models include survey research, single-case designs, and qualitative studies. However, based on current mental health care reimbursement practices and future trends, providers are increasingly expected to provide services consistent with findings from efficacy and effectiveness research (Cuijpers et al., 2023).
In Pursuit of Research-Supported Psychological Treatments
Procedure-oriented researchers and practitioners believe the active mechanism producing positive psychotherapy outcomes is therapy technique. Common factors proponents support the dodo bird declaration. To make matters more complex, prestigious researchers who don’t have allegiance to one side or the other typically conclude that we don’t have enough evidence to answer these difficult questions about what ingredients create change in psychotherapy (Cuijpers et al., 2019). Here’s what we know: Therapy usually works for most people. Here’s what we don’t know: What, exactly, produces positive changes.
For now, the question shouldn’t be, “Techniques or common factors?” Instead, we should be asking “How do techniques and common factors operate together to produce positive therapy outcomes?” We should also be asking, “Which approaches and techniques work most efficiently for which problems and populations?” To be broadly consistent with the research, we should combine principles and techniques from common factors and EST perspectives. We suspect that the best EST providers also use common factors, and the best common factors clinicians sometimes use empirically supported techniques.
Naming and Claiming What Works
When it comes to naming and claiming what works in psychotherapy, we have a naming problem. Every day, more research information about psychotherapy efficacy and effectiveness rolls in. As a budding clinician, you should track as much of this new research information as is reasonable. To help you navigate the language of researchers and practitioners use to describe “What works,” here’s a short roadmap to the naming and claiming of what works in psychotherapy.
When Klerman (1986) stated, “We must come to view psychotherapy as we do aspirin” his analogy was ironic. Aspirin’s mechanisms and range of effects have been and continue to be complex and sometimes mysterious (Sommers-Flanagan, 2015). Such is also the case with counseling and psychotherapy.
Language matters, and researchers and practitioners have created many ways to describe therapy effectiveness.
D12 briefly used the phrase empirically validated psychotherapy. Given that psychotherapy outcomes vary, the word validated is generally avoided.
In the face of criticism, D12 blinked once, renaming their procedures as empirically supported psychotherapy. ESTs are manualized and designed to treat specific mental disorders or specific client problems. If it’s not manualized and doesn’t target a disorder/problem, it’s not an EST.
ESTs have proliferated. As of this moment (August 2025), 89 ESTs for 30 different psychological disorders and behavior problems are listed on the Division 12 website (https://div12.org/psychological-treatments/). You can search the website to find the research status of various treatments.
To become proficient in providing an EST requires professional training. Certification may be necessary. It’s impossible to obtain training to implement all the ESTs available.
In 2006, an APA Presidential Task Force (2006) loosened D12’s definition, shifting to a more flexible term, Evidence-Based Practice (EBP), and defining it as ‘‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences’’ (p. 273).
In 2007, the Journal of Counseling and Development, the American Counseling Association’s flagship journal, inaugurated a new journal section, “Best Practices.” As we’ve written elsewhere, best practice has grown subjective and generic and is “often used so inconsistently that it is nearly meaningless” (Sommers-Flanagan, 2015, p. 98).
In 2011, D12 relaunched their website, relabeling ESTs as research-supported psychological treatments (n.b., most researchers and practitioners continue to refer to ESTs instead of research-supported psychological treatments).
As an alternative source of research updates, you can also track the prolific work of Pim Cuijpers and his research team for regular meta-analyses on psychological treatments (Cuijpers et al., 2023; Harrer et al., 2025).
Other naming variations, all designed to convey the message that specific treatments have research support, include evidence-based treatment, evidence-supported treatment, and other phrasings that, in contrast to ESTs and APA’s evidence-based practice definition, have no formal definition.
Manuals, Fidelity, and Creativity
Manualized treatments require therapist fidelity. In psychotherapy, fidelity means exactness or faithfulness to the published procedure—meaning you follow the manual. However, in the real world, when it comes to treatment fidelity, therapist practice varies. Some therapists follow manuals to the letter. Others use the manual as an outline. Still others read the manual, put it aside, and infuse their therapeutic creativity.
A seasoned therapist (Bernard) we know recently provided a short, informal description of his application of exposure therapy to adult and child clients diagnosed with obsessive-compulsive disorder. Bernard described interactions where his adult clients sobbed with relief upon getting a diagnosis. Most manuals don’t specify how to respond to clients sobbing, so he provided empathy, support, and encouragement. Bernard described a therapy scenario where the client’s final exposure trial involved the client standing behind Bernard and holding a sharp kitchen knife at Bernard’s neck. This level of risk-taking and intimacy also isn’t in the manual—but Bernard’s client benefited from Bernard trusting him and his impulse control.
During his presentation, Bernard’s colleagues chimed in, noting that Bernard was known for eliciting boisterous laughter from anxiety-plagued children and teenagers. There’s no manual available on using humor with clients, especially youth with overwhelming obsessional anxiety. Bernard used humor anyway. Although Bernard had read the manuals, his exposure treatments were laced with empathy, creativity, real-world relevance, and humor. Much to his clients’ benefit, Bernard’s approach was far outside the manualized box (B. Balleweg, personal communication, July 14, 2025).
As Norcross and Lambert (2018) wrote: “Treatment methods are relational acts” (p. 5). The reverse is equally applicable, “Relational acts are treatment methods.” As you move into your therapeutic future, we hope you will take the more challenging path, learning how to apply BOTH the techniques AND the common factors. You might think of this—like Bernard—as practicing the science and art of psychotherapy.
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Note: This is a draft excerpt from Chapter 1 of our 4th edition, coming out in 2026. As a draft, your input is especially helpful. Please share as to whether the rabbit hole was too deep, not deep enough, just right, and anything else you’re inspired to share.
A friend and colleague in the Counseling Department at the University of Montana forwarded me an article by Lucy Foulkes of Oxford University titled, “Mental-health lessons in schools sound like a great idea. The trouble is, they don’t work.”
That is troubling. My friend knows I’ve been thinking about these things for years . . . and I feel troubled about it too.
Children’s behavioral or mental or emotional health has been in decline for decades. COVID made things worse. Even at the University, our collective impression is that current students—most of whom are simply fantastic—are more emotionally fragile than we’ve ever seen before.
As Craig Bryan says in his remarkable book, “Rethinking Suicide,” big societal problems like suicide, homelessness, addiction, and mental health are “wicked problems” that often respond to well-intended efforts by not responding, or by getting worse.
Such is the case that Lisa Foulkes is describing in her article.
I’ve had a front row seat to mental health problems getting worse for about 42 years now. Oh my. That’s saying something. Mostly it’s saying something about my age. But other than my frightening age, my point is that in my 42+ years as a mental health professional, virtually everything in the mental health domain has gotten worse. And when I say virtually, I mean literally.
Anxiety is worse. Depression is worse. ADHD is worse, not to mention bipolar, autism spectrum disorder, suicide, and spectacular rises in trauma. I often wonder, given that we have more evidence-based treatments than ever before in the history of time . . . and we have more evidence-based mental health prevention programming than ever before in the history of time . . . how could everything mental health just keep on going backward? The math doesn’t work.
In her article, Lisa Foulkes points out that mental health prevention in schools doesn’t work. To me, this comes as no big surprise. About 10 years ago, mental health literacy in schools became a big deal. I remember feeling weird about mental health literacy, partly because across my four decades as an educator, I discovered early on that if I presented the diagnostic criteria for ADHD to a class of graduate students, about 80% of them would walk away thinking they had ADHD. That’s just the way mental health literacy works. It’s like medical student’s disease; the more you learn about what might be wrong with you the more aware and focused you become on what’s wrong with you. We’ve known this since at least the 1800s.
But okay, let’s teach kids about mental health disorders anyway. Actually, we’re sort of trapped into doing this, because if we don’t, everything they learn will be from TikTok. . . which will likely generate even worse outcomes.
I’m also nervous about mindful body scans (which Foulkes mentions), because they nearly always backfire as well. As people scan their bodies what do they notice? One thing they don’t notice is all the stuff that’s working perfectly. Instead, their brains immediately begin scrutinizing what might be wrong, lingering on a little gallop in their heart rhythm or a little shortness of breath or a little something that itches.
Not only does mental health education/prevention not work in schools, neither does depression screenings or suicide screenings. Anyone who tells you that any of these programs produces large and positive effects is either selling you something, lying, or poorly informed. Even when or if mental health interventions work, they work in small and modest ways. Sadly, we all go to bed at night and wake up in the morning with the same brain. How could we expect large, dramatic, and transformative positive outcomes?
At this point you—along with my wife and my team at the Center for the Advancement of Positive Education—may be thinking I’ve become a negative-Norman curmudgeon who scrutinizes and complains about everything. Could be. But on my good days, I think of myself as a relatively objective scientist who’s unwilling to believe in any “secret” or public approaches that produce remarkably positive results. This is disappointing for a guy who once hoped to develop psychic powers and skills for miraculously curing everyone from whatever ailed them. My old college roommate fed my “healer” delusions when, after being diagnosed with MS, “I think you’ll find the cure.”
The painful reality was and is that I found nothing helpful about MS, and although I truly believe I’ve helped many individuals with their mental health problems, I’ve discovered nothing that could or would change the negative trajectory of physical or mental health problems in America. These days, I cringe when anyone calls themselves a healer. [Okay. That’s likely TMI.]
All this may sound ironic coming from a clinical psychologist and counselor educator who consistently promotes strategies for happiness and well-being. After what I’ve written above, who am I to recommend anything? I ask that question with full awareness of what comes next in this blog. Who am I to offer guidance and educational opportunities? You decide. Here we go!
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The Center for the Advancement of Positive Education (CAPE) and the Montana Happiness Project (that means me and my team) are delighted to be a part of the upcoming Jeremy Bullock Safe Schools Conference in Billings, MT. The main conference will be Aug 5-6. You can register for the conference here: https://jeremybullocksafeschools.com/register. The flyer with a QR code is here:
In the same location, beginning on the afternoon of Aug 6 and continuing for most of Aug 7, CAPE is offering a “Montana Happiness” infused 7-hour bonus training. Using our combined creative skills, we’ve decided to call our workshop: “Happiness for Educators.” Here’s the link to sign up for either a one-credit UM grad course (extra work is required) or 7 OPI units: https://www.campusce.net/umextended/course/course.aspx?C=763&pc=13&mc=&sc=
The flyer for our workshop, with our UM grad course or OPI QR code is at the top of this blog post.
In the final chapter of Rethinking Suicide, Craig Bryan, having reviewed and lamented our collective inability to prevent suicide, turns toward what he views as our most hopeful option: Helping people create lives worth living. Like me, Dr. Bryan has shifted from a traditional suicide prevention perspective to strategies for helping people live lives that are just a little more happy, meaningful, and that include healthy supportive relationships. IMHO, this positive direction provides hope.
In our Billings workshop, we’ll share, discuss, and experience evidence-based happiness strategies. We’ll do this together. We’ll do it together because, in the words of the late Christopher Peterson, “Other people matter. And we are all other people to everyone else.”
Come and join us in Billings . . . for the whole conference . . . or for our workshop . . . or for both.
I’ve been in repeated conversations with numerous concerned people about the risks and benefits of suicide screenings for youth in schools. Several years ago, I was in a one-on-one coffee shop discussion of suicide prevention with a local suicide prevention coordinator. She said, more as a statement than a question, “Who could be against school-based depression and suicide screenings?”
I slowly raised my hand, forced a smile, and confessed my position.
The question of how and why I’m not in favor of school-based mental health and suicide screenings is a complex one. On occasion, screenings will work, students at high-risk will be identified, and tragedy is averted. That’s obviously a great outcome. But I believe the mental health casualties from broad, school-based screenings tend to outweigh the benefits. Here’s why.
Early identification of depression and suicide in youth will result in early labeling in school systems; even worse, young people will begin labeling themselves as being “ill” or “defective.” Those labels are sticky and won’t support positive outcomes.
Most youth who experience depressive symptoms and suicide ideation are NOT likely to die by suicide. Odds are that students who don’t report suicidal ideation are just as likely to die by suicide. As the scientists put it, suicidal ideation is not a good predictor of suicide. Also, depression symptoms generally come and go among teenagers. Most teens will recover from depressive symptoms without intensive interventions.
After a year or two of school-based screenings, the students will know the drill. They will realize that if they endorse depression symptoms and suicidal items that they’ll have to experience a pretty horrible assessment and referral process. When I talk to school personnel, they tell me that, (a) they already know the students who are struggling, and (b) in year 2 of screenings, the rates of depression and suicidality plummet—because students are smart and they want to avoid the consequences of being open about their emotional state.
About 10-15% of people who complete suicide screenings feel worse afterward. We don’t really want that outcome.
There’s no evidence that school-based screenings are linked to reductions in suicide rates.
For more info on this, you can check out a brief commentary I published in the American Psychologist with my University of Montana colleague, Maegan Rides At The Door. The commentary focuses on suicide assessment with youth of color, but our points work for all youth. And, citations supporting our perspective are included.
Here are a few excerpts from the commentary:
Standardized questionnaires, although well-intended and sometimes helpful, can be emotionally activating and their use is not without risk (Bryan, 2022; de Beurs et al., 2016).
In their most recent recommendations, the United States Preventive Services Task Force (2022) concluded that the evidence supporting screening for suicide risk among children and adolescents was “insufficient” (p. 1534). Even screening proponents acknowledge, “There is currently little to no data to show that screening decreases suicide attempt or death rates” (Cwik et al., 2020, p. 255). . . . Across settings, little to no empirical evidence indicates that screening assessments provide accurate, predictive, or useful information for categorizing risk (Bryan, 2022).
Uncommon Courses is an occasional series from The Conversation U.S. highlighting unconventional approaches to teaching.
Title of Course
Evidence-Based Happiness for Teachers
What prompted the idea for the course?
I was discouraged. For nearly three decades, as a clinical psychologist, I trained mental health professionals on suicide assessment. The work was good but difficult.
I consulted my wife, Rita, who also happens to be my favorite clinical psychologist. We decided to explore the science of happiness. Together, we established the Montana Happiness Project and began offering evidence-based happiness workshops to complement our suicide prevention work.
In 2021, the Arthur M. Blank Family Foundation, through the University of Montana, awarded us a US$150,000 grant to support the state’s K-12 public school teachers, counselors and staff. We’re using the funds to offer these educators low-cost, online graduate courses on happiness. In spring 2023, the foundation awarded us another $150,000 so we could extend the program through December 2025.
What does the course explore?
Using the word “happiness” can be off-putting. Sometimes, people associate happiness with recommendations to just smile, cheer up and suppress negative emotions – which can lead to toxic positivity.
As mental health professionals, my wife and I reject that definition. Instead, we embrace Aristotle’s concept of “eudaimonic happiness”: the daily pursuit of meaning, mutually supportive relationships and becoming the best possible version of yourself.
The heart of the course is an academic, personal and experiential exploration of evidence-based positive psychology interventions. These are intentional practices that can improve mood, optimism, relationships and physical wellness and offer a sense of purpose. Examples include gratitude, acts of kindness, savoring, mindfulness, mood music, practicing forgiveness and journaling about your best possible future self.
Students are required to implement at least 10 of 14 positive psychology interventions, and then to talk and write about their experiences on implementing them.
The lesson on sleep is especially powerful for educators. A review of 33 studies from 15 countries reported that 36% to 61% of K-12 teachers suffered from insomnia. Although the rates varied across studies, sleep problems were generally worse when teachers were exposed to classroom violence, had low job satisfaction and were experiencing depressive symptoms.
The sleep lesson includes, along with sleep hygiene strategies, a happiness practice and insomnia intervention called Three Good Things, developed by the renowned positive psychologist Martin Seligman.
I describe the technique, in Seligman’s words: “Write down, for one week, before you go to sleep, three things that went well for you during the day, and then reflect on why they went well.”
Next, I make light of the concept: “I’ve always thought Three Good Things was hokey, simplistic and silly.” I show a video of Seligman saying, “I don’t need to recommend beyond a week, typically … because when you do this, you find you like it so much, most people just keep doing it.” At that point, I roll my eyes and say, “Maybe.”
Then I share that I often awakened for years at 4 a.m. with terribly dark thoughts. Then – funny thing – I tried using Three Good Things in the middle of the night. It wasn’t a perfect solution, but it was a vast improvement over lying helplessly in bed while negative thoughts pummeled me.
The Three Good Things lesson is emblematic of how we encourage teachers in our course – using science, playful cynicism and an open and experimental mindset to apply the evidence-based happiness practices in ways that work for them.
I also encourage students to understand that the strategies I offer are not universally effective. What works for others may not work for them, which is why they should experiment with many different approaches.
What will the course prepare students to do?
The educators leave the course with a written lesson plan they can implement at their school, if they wish. As they deepen their happiness practice, they can also share it with other teachers, their students and their families.
Over the past 16 months, we’ve taught this course to 156 K-12 educators and other school personnel. In a not-yet-published survey that we carried out, more than 30% of the participants scored as clinically depressed prior to starting the class, compared with just under 13% immediately after the class.
The educators also reported overall better health after taking the class. Along with improved sleep, they took fewer sick days, experienced fewer headaches and reported reductions in cold, flu and stomach symptoms.
As resources allow, we plan to tailor these courses to other people with high-stress jobs. Already, we are receiving requests from police officers, health care providers, veterinarians and construction workers.
Why Do We Need a Strengths-Based Approach to Suicide Assessment and Treatment?
Imagine this: You’re living in a world that seems like it would just as soon forget you exist. Maybe your skin color is different than the dominant people who hold power. Maybe you have a disability. Whatever the case, the message you hear from the culture is that you’re not important and not worthy. You feel oppressed, marginalized, unsupported, and as if much of society would just as soon have you become invisible or go away.
In response, you intermittently feel depressed and suicidal. Then, when you enter the office of a health or mental health professional, the professional asks you about depression and suicide. Even if the professional is well-intended, judgment leaks through. If you admit to feeling depressed and having suicidal thoughts, you’ll get a diagnosis that implies you’re to blame for having depressing and suicidal thoughts.
The medical model overfocuses on trying to determine: “Are you suicidal?” The medical model is also based on the assumption that the presence of suicidality indicates there’s something seriously wrong with you. But if we’re working with someone who has been or is currently being marginalized, a rational response from the patient might be:
“As it turns out, I’ve internalized systemic and intergenerational racism, sexism, ableism, and other dehumanizing messages from society. I’ve been devalued for so long and so often that now, I’ve internalized societal messages: I devalue myself and wonder if life is worth living. And now, you’re blaming me with a label that implies I’m the problem!”
No wonder most people who are feeling suicidal don’t bother telling their health professionals.
When I think of this preceding scenario, I want to add profanity into my response, so I can adequately convey that it’s completely unjust to BLAME patients for absorbing repeated negative messages about people who look like or sound like or act like them. WTH else do you think should happen?
This is why we need to integrate strengths-based principles into traditional suicide assessment and prevention models. Of course, we shouldn’t use strengths-based ideas in ways that are toxically positive. We ALWAYS need to start by coming alongside and feeling with our patients and clients. As it turns out, if we do a good job of coming alongside patients/clients who are in emotional pain, natural opportunities for focus on strengths and resources, including cultural, racial, sexual, and other identities that give the person meaning.
I’m reminded of an interview I did with an Alaskan Native person from the Yupik tribe. She talked at length about her depression, about feeling like a zombie, and past and current suicidal thoughts. Eventually, I inquired: “What’s happening when you’re not having thoughts about suicide?” She seemed surprised. Then she said, “I’d be singing or writing poetry.” I instantly had a sense that expressing herself held meaning for her. In particular, her singing Native songs and contemporary pop songs became important in our collaborative efforts to build her a safety plan.
This coming Wednesday morning I have the honor of presenting as the keynote speaker for the Maryland Department of Health 36th Annual Suicide Prevention Conference. During this keynote, I’ll share more ideas about why a strengths-based model is a good fit when working with diverse clients who are experiencing suicidal thoughts and impulses.
With all that said, here’s the title and abstract of my upcoming presentation.
Strengths-Based Assessment, Treatment, and Prevention with Diverse Populations
Traditional suicide assessment tends to be a top-down information-gathering process wherein healthcare or prevention professionals use questionnaires and clinical interviews to determine patient or client suicide risk. This approach may not be the best fit for people from populations with historical trauma, or for people who continue to experience oppression or marginalization. In this presentation, John Sommers-Flanagan will review principles of a strengths-based approach to suicide prevention, assessment, and treatment. He will also discuss how to be more sensitive, empowering, collaborative, and how to leverage cultural strengths when working with people who are potentially suicidal. You will learn at least three practical strengths-based strategies for initiating conversations about suicide, conducting culturally-sensitive assessments, and implementing suicide interventions—that you can immediately use in your prevention work.
Last week I got a press query to answer a few questions for an upcoming article in Parents magazine. The questions were sent to a broad spectrum of media reps and professionals. There was understandably no guarantee I would be quoted in the magazine.
No surprise, I wasn’t quoted. But my media connection was thoughtful enough to send me the article (it came out a couple days ago). IMHO commentary in the article was really good, and so I’m including a link to the article below.
Although I like the article, I have one objection. The authors immediately pathologize children’s anxiety. In the second sentence of the article, they write, “Both conditions (separation anxiety and social anxiety) are treatable with the proper diagnosis.” Using words like “conditions” and “treatable” and “diagnosis” deeply medicalizes children’s anxiety and is a bad idea. Separation anxiety and social anxiety are NOT necessarily mental disorders. It would have been better to start the article by noting that given our current global situation of uncertainty–with COVID, and other sources of angst all around us–it’s normal and natural for children to feel anxiety.
This blog post has three parts. First, I’m including a link to the article. Second, I’m including my responses to the media query. Third—and I think the best part—is a old handout I wrote for helping parents deal with children’s anxiety and fear.
Here are my responses to the magazine’s questions:
What is anxiety, in a nutshell?
Anxiety is a natural human emotional response to stress, danger, or threat. One thing that makes anxiety especially distinctive and problematic is that it comes with strong physiological components. Other words used to describe anxiety states include, nervous, worried, jittery, jumpy, scared, and afraid.
Anxiety usually has a trigger or is linked to an activating situation, thought, or physical sensation. Hearing about COVID in the news or seeing someone fall ill can activate anxiety in children (and adults too!).
Anxiety is often, but not always, about the future because people tend to worry about what will happen or what is unfolding in the present. Even when children feel anxious about the past, they tend to worry about how the past will play out in the future.
How has COVID-19 affected children mentally? Has there been an uptick in anxiety-related conditions?
COVID-19 is a stressor or threat because of its implications (it can kill you and your loved ones) and because of how it affects children situationally. During my 30+ years as a professional psychologist, anxiety in children, teens, and adults has done nothing but increase. COVID-19 is another factor in contemporary life that has increased anxiety.
In some ways, the fact that more children are feeling anxious can be a positive thing. I know that sounds weird, but anxiety is mostly normal. A professor of mine used to say that the old saying “Misery loves company” isn’t quite true. What is true (and supported by data) is that misery loves miserable company. In other word, people feel a little better when their problems are more universal. When it comes to COVID-related anxiety, we should all recognize we’re in good company.
What are the symptoms of social anxiety in kids?
Social anxiety is defined as fear of being scrutinized or negatively evaluated by others. Symptoms can be physical (headaches, stomach aches, shaking, etc.), emotional (feeling scared), mental (thinking something terrible will happen), and behavioral (running away). Social anxiety is usually most intense in anticipation and during exposure to potential social evaluation. Of course, almost always, anxiety will make us imagine that everyone is staring at us—even though many other kids are also feeling anxious and as if everyone is staring at them.
What are the symptoms of separation anxiety in kids?
Separation anxiety occurs when children leave or part from a safe person or a safe place. Leaving the home or leaving mom or dad or grandma or grandpa will often trigger anxiety. The symptoms—because it’s anxiety—are the same as above (physical, emotional, mental, behavioral); they’re just triggered by a different situation.
How can you help children cope with anxiety–both in general and specific to each condition?
Children should be assured that anxiety is a message from your brain and your body. When anxiety spikes, there may be a good reason for it, just like when a fire alarm goes off and there’s really a fire and there’s physical danger and getting to a safe place is important. Children should be encouraged to identify their safe places and their safe people.
However, sometimes anxiety spikes and instead of a real fire alarm, the body and the brain are experiencing a false alarm. When there’s no immediate danger and the anxiety builds up anyway, it’s crucial for children to have a plan for how they’ll handle the anxiety. Having a plan to approach and deal with anxiety is nearly always preferable to letting the anxiety be the boss. Leaning into, facing, and embracing anxiety as a normal part of life is very important. We should all avoid taking actions designed to run away from or avoid anxiety. Developing a personal plan (along with parents, teachers, and counselors) for dealing with anxiety is the best strategy.
And, finally, here’s my tip sheet for helping with children’s anxiety
How to Help Children Deal with Fears and Anxiety
Manage Your Own Anxiety and Negative Expectations: If you don’t have and display confidence in your own preparation and skills, YOUR WORRIES and negative expectations will leak into the child. Additionally, if you don’t show confidence in your child’s coping abilities, that lack of confidence will leak into them too!
Use Storytelling for Preparation and to Teach Coping Strategies: “Let’s read, Where the Wild Things Are.” Afterwards, launch into a discussion of how people deal with fears.
Focus on Problem-Solving and Coping (especially as preparation): “How do you suppose people manage or get over their fears?”
Instead of Dismissing Feelings, Use Soothing Empathy: “It’s no fun to be feeling so scared.”
Show Gentle Curiosity: “You seem scared. Want to talk about it?”
Provide Comforting Reassurance or Universality (after using empathy and listening with interest): “Lots of people get afraid of things. I remember being really afraid of dogs.”
Offer Positive (Optimistic) Encouragement: “I know it’s hard to be brave, but I know you can do it.”
Have and Show Enormous Patience (connection—and holding hands—reduces anxiety): “Yes, I’ll help you walk by Mr. Johnson’s dog again. I think we’re both getting better at it, though.”
Set Reasonable Limits: “Even though you’re scared of monsters sometimes, you still have to be brave and go to bed.”
Model how to Sit with and through Fear (No negative reinforcement!): One thing that’s always true is when fear is big, it always gets smaller, eventually. “Hey. Let’s sit here together and watch our fear go away. Let’s pay attention to what makes it get smaller.” (This might include direct coping skill work . . . or simple distraction and funny stories).
Plan and Model Anxiety Management Skills: Specific skills, like deep breathing, aid with coping. Once you find some techniques or skills that are better than nothing, start to practice and rehearse using them. This can be for preparation, coping during the anxiety, or afterwards. “Let’s sit together and count our breaths. Just count one and then another. And we’ll try to find our sweet spot.”
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John Sommers-Flanagan 