Tag Archives: artificial-intelligence

The Best Suicide Prevention Questionnaires. . . and Upcoming Events

An online friend in Richmond, Virginia with a mutual interest in suicide prevention emailed asking a question about my perspective on using assessment questionnaires to conduct suicide risk assessments.

She shared a post from a listserv called PAUSE (People Addressing and Understanding Suicide Experiences). The PAUSE post used Gemini to explore the question: “How effective is the C-SSRS (aka “the Columbia”) in predicting and eliminating false positives in individual risk assessment situations?”

Gemini’s AI discussion was fascinating—in all the ways you might imagine. 

Gemini led with the basic truth that suicide prediction suffers from the statistical “Low base rate problem.” The low frequency (or low base rate) of death by suicide in the general population makes it nearly impossible to predict without having too many false positives. A false positive in suicide assessment is when someone is identified as “high risk” for suicide, but the true risk is not high. Because the U.S. has about 14 suicide deaths per 100,000 people, prediction efforts tend to produce a plethora of false positives, making accurate predictions difficult.

The bigger problem in suicide assessment and screening is the problem of the false negatives. Gemini wasn’t asked about false negatives and didn’t go there. A false negative occurs when the instrument or clinician concludes “low risk” when, in fact, risk is high. This is a bigger problem because false negatives can lead to death whereas false positives lead to overidentification or unnecessary intervention. This bigger problem may be why Craig Bryan advises against using instruments to categorize risk. Because death by suicide is often driven by acute variables (e.g., a relationship break-up, intoxication, job loss, etc.), categorizing anyone as “low risk” based on a screening or assessment will result in too many cases where suicidality is tragically underestimated.

I’d love to dive deeper into questionnaires, actuarial vs. clinical assessment, and the science of predicting human behavior (which was the topic of my Master’s thesis and Doctoral dissertation). However, I’m stopping here because I don’t want to go down the same road as Gemini. . .which is a road with lots of information and statistics and that almost COMPLETELY MISSES THE POINT. What is the point? Suicide assessment questionnaires never prevent suicide.

I should put that statement in ALL BOLD CAPS. To repeat:

SUICIDE ASSESSMENT QUESTIONNAIRES NEVER PREVENT SUICIDE.

Suicide assessment questionnaires are tools that help, but they cannot save lives. Suicide assessments must be used by clinicians; clinicians are the driving force in prevention and saving lives. Here’s another point that deserves bolding and all caps.

ONLY CLINICIANS, FRIENDS, COWORKERS, FAMILY, OR OTHER HUMANS PREVENT SUICIDE AND SAVE LIVES.

As much as I love exploring statistics, science, and prediction all these fascinating concepts cannot replace human connection, trusting relationships, and skills-based interventions.  Suicide assessment questionnaires, checklists, and screenings are tools. That’s all.

Since way back in the 1970s, the general rule in the world of psychological assessment has been that actuarial based assessment is a better prediction tool than clinician assessment. This is probably still true, but when we’re talking about human behavior and suicide, the answer is sometimes “it depends.”

So. . . “Which suicide questionnaire is the best for predicting and preventing suicide?” Although I think questionnaire validity and reliability are important, in the case of suicide assessment, the underlying statistics are nearly irrelevant. What’s relevant is whether a specific clinician can use a specific questionnaire to connect with, care for, and effectively a specific person who is suicidal.

Assessment instruments and efforts to accurately predict suicide risk are so intellectually fascinating that we often risk missing the point. Suicide prevention is extremely difficult, suicide prediction is extremely difficult, and the success of prediction and prevention efforts depend almost completely on human interaction.

Thanks for reading.

In case you’re interested—and especially for my Virginia and Alabama friends—this week I’ll be in Virginia doing three presentations at the Virginia Counseling Association conference in Norfolk, VA on Thursday, November 12.

https://cdn.ymaws.com/www.vcacounselors.org/resource/resmgr/2026_vca_convention/2026_VCA_Convention_Program.pdf

Next week I’ll be at Virginia Commonwealth University on Monday November 16.

Then I’ll be at the Bon Air Library in Richmond doing a suicide-related Lunch N’ Learn on Tuesday, November 17 (see above).

On Thursday, November 19, I’ll be in Mobile, Alabama doing two presentations at the Alabama Counseling Association.

https://www.alabamacounseling.org/uploads/1/2/3/9/123960750/2026_alca_new_brochureflyer.pdf

Big thanks go to Robert Froelich of VCA, Waganesh Zeleke of VCU, Erin Gallagher of Jay Walkers, and Daniel Birdsong of ALCA for organizing all these events.

The Theories Series: What’s New in the 4th Edition?

Today I found a creepy AI audio summary of the 3rd edition of our theories text. Maybe I should have liked it, because it was super-glowing. But the AI voice overweening on my behalf felt wrong.

In contrast, the following content is real and excerpted from our forthcoming 4th edition of Counseling and Psychotherapy Theories in Context and Practice

To continue with the creepy, the following is what was generated when I asked ChatGPT to create an image of itself.

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Theories and lenses are tools we use to make sense of our complicated world. We’re not saying that the world is more complicated in 2026 than it was 23 years ago, when the first version of this text was published, but the proliferation of information in the modern digital age means that there’s more to sift through than our brains can handle. We hope this text provides you with intellectual structure, insights, practical tools, and fun companionship on your road to understanding and engaging in counseling and psychotherapy. 

While walking across the University of Montana campus the other day (which is beautiful on any day, but especially during the fall here in Montana), we noticed an annual tradition on campus had recurred—a fresh, large, orange pumpkin was placed on the top of a spire on University Hall, over 100 feet above the ground, just in time for Halloween. The impossibly steep roof of the clock tower, and the brazenness of putting a fresh gourd up there each year (for decades!) leads to speculation—let’s call them theories—about how a pumpkin could possibly make it on top of the spire.

Is it a renegade group of rock climbers who scale the building each October? Is the University somehow complicit in keeping the tradition alive while sternly warning students not to climb the building? With advancements in drone technology, has someone figured out how to hoist a heavy pumpkin and drop it on that precise point? Is it a 3-D optical phenomenon that doesn’t exist other than in socially constructed reality?

Which theory is correct? But what if it’s not one theory; maybe the pumpkin tradition has evolved over time. After decades of being on campus, our guess is, we’ll never know. The same is probably true with theories and lenses of counseling. We’ll never know—for certain—if the perspective we take is “the correct” one. The best we can do is continue learning about human behavior and the theories that explain it and do our best for our clients by using lenses and theories to help understand their unique situations and help make things better. The pumpkin problem is much easier.

We encourage you to carry theories and lenses from this textbook around with you to help you to make sense of the world—not just in terms of counseling and therapy, but in terms of understanding complexities of the world we live in. At a time where there’s a tendency to over-rely on artificial intelligence to get “the answer” to your questions, playing with different theories is good for your neural connectivity—and probably good for your clients’ well-being, because embracing and valuing different perspectives is good for all of us as we try to navigate this wildly complex world.

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We believe in several things: First, we cannot help but be affected by contemporary socio-cultural-political events. Second, regardless of socio-cultural-political movements, the counseling and psychotherapy space needs to be safe, sacred, and inclusive for everyone, and especially people with limited resources, diverse identities, and a history of distress or trauma. Third, although we talk about creating a safe space for clients to explore their lives, our offices are not instantly safe, and simply saying the words, “this is a safe space” won’t magically create trust and safety. We need work with clients to, over time, make it experientially safe.

We hope you can use the theories in this text to create and support an inclusive psychotherapy where positive and transformative work happens.

WHAT’S NEW IN THE FOURTH EDITION?

We’ve been receiving solicited and unsolicited feedback on this “Theories text” since 2003. Most of the feedback has been overwhelmingly positive. At conferences, people often approach us and say how much they love this book. They love the anecdotes, our irreverent attitudes, and our occasional efforts at humor. Yes, we believe this theories text is the funniest one on the market. Positive feedback from students and faculty has been incredibly affirming, mostly because our primary goals were to create an engaging, interesting, and practical theories text.

As a side note, we recognize there’s not much competition for funniest theories book on the market. But if there was a formal theories textbook humor competition, we would win hands down.

We’ve also received constructive feedback. Although less affirming, constructive feedback is essential to our personal and professional growth and development. We’ve tried to use constructive feedback to create an even better textbook. We invite you to provide us with whatever type of feedback you like.

So. . .what’s new in the Fourth Edition?

To add perspective to the text, we added a co-author. Bryan Cochran is a professor of psychology and LGBTIQ+ scholar. His voice and perspective are woven into every chapter, but especially our two new chapters. In chapter 2, Bryan describes several lenses that influence how we all practice counseling and psychotherapy. These lenses include: (a) Critical race theory; (b) Queer theory; (c) Intersectionality, and (d) a few other important contemporary perspectives. These lenses are not counseling or psychotherapy theories, but they can and should be used with theories and evidence-based approaches to make us more sensitive, humble, and competent in working with all clients.

In chapter 13, Bryan takes us on a deep dive into third wave behavioral treatments. These treatments include:

  1. Mindfulness-based stress reduction (MBSR),
  2. Dialectical behavior therapy (DBT),
  3. Prolonged exposure (PE), and
  4. The unified protocol (UP).

Each of these treatments incorporate mindfulness; they also have substantial empirical support. Learning about them will make you a better therapist.

To better address culture and social justice issues, we’ve done what Derald Wing Sue recommended 15 years ago. We eliminated the “multicultural chapter” and distributed cultural and diversity content throughout the other chapters, with a big emphasis in chapter 2. Our goal was to more fully integrate diversity into all theoretical approaches. We look forward to hearing from you regarding whether we accomplished that goal.

As before, every chapter includes sub-sections titled (a) cultural sensitivity, (b) gender and sexuality, and (c) spirituality. As it turns out, we still haven’t discovered the neurological basis of everything, but apparently folks are still trying. Neuroscience is featured in chapter 1 and incorporated throughout the text via the “Brain Box” feature that appears in most chapters.

WORDS TO (and from) THE WISE

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Language is liberating and activating. Although we’ve done our best to follow professional language guidelines, no doubt, sometimes you will react to our language choices, our examples, and our content. If we were in the same room as you as you had an emotional reaction, we would say something like, “Thank you for your passion.” And then we would do our best to non-defensively explore your reaction and our language, example, or content. If you engage in class discussions with classmates (or your instructor) about this text, we hope you will afford each other mutual respect and compassion for the emotions that can and will arise from studying counseling and psychotherapy.