Textbook writing is a particular kind of writing that requires a variety of ways to present relatively boring material to students and aspiring professionals. Although we pride ourselves on writing the most entertaining textbooks in the business, our efforts to entertain are all part of a reader-friendly delivery system.
Another (less humorous) reader-friendly delivery strategy is the checklist. We intermittently use checklists to summarize essential information in our Clinical Interviewing text. Below, I’m including links to three checklists. Please note, these checklists are in process, and so if you see any typos or missing information or have some excellent feedback to share with me . . . post your feedback here on this blog or email me: john.sf@mso.umt.edu. I will greatly appreciate your feedback!
From Chapter 10: A Checklist on Suicide Assessment Documentation:
For those of you who are still reading (and I hope that’s everyone), I’m still looking for someone who can write me a short (400 word) case or two on working with LGBTQ+ youth. A transgender case would be especially nice. If you’re interested, send me an email: john.sf@mso.umt.edu
I’m in Enterprise, Oregon today and tomorrow morning. I got here Sunday evening after a winding ride through forests and mountains. Yes, I’m in Eastern Oregon. Even I, having attended Mount Hood Community College and Oregon State University, had no idea there were forests and mountains in Enterprise.
The scenes are seriously amazing, but the people at the Wallowa Valley Center for Wellness-where I’m doing a series of presentations on suicide assessment and prevention-are no less amazing. I’ve been VERY pleasantly surprised at the quality, competence, and kindness of the staff and community.
Just in case you’re interested, below I’m posting ppts for my three different presentations. They overlap, but are somewhat distinct.
On September 24, I’m doing a full-day online-only Strengths-Based Suicide Assessment and Treatment Planning workshop. The workshop is on behalf of the Association for Humanistic Counselors . . . a cool professional organization if there ever was one.
Just in case you want two-days of Strengths-Based Suicide Training or you want to come to the U of Montana or you need some college credit, we’ve got a full two-day version of the workshop happening in Missoula on November 19 and 20. In addition, if you’re wanting a continuing education smörgåsbord, this link also includes two day trainings with the fabulous Dr. Kirsten Murray (Strong Couples) and the amazing Dr. Bryan Cochran (LGBTQI+ Clients). Here’s that link: https://www.familiesfirstmt.org/umworkshops.html
There’s more happening too . . . but for now, this is probably enough for one post.
Have a fantastic week, and don’t be afraid to be the early bird.
By embracing a holistic, strengths-based and wellness orientation in their work with clients who may be suicidal, counselors can improve on traditional approaches to suicide assessment and treatment
By John and Rita Sommers-Flanagan
When the word “suicide” comes up during counseling sessions, it usually triggers clinician anxiety. You might begin having thoughts such as, “What should I ask next? How can I best evaluate my client’s suicide risk? Should I do a formal suicide assessment, or should I be less direct?” In addition, you might worry about possible hospitalization and how to make the session therapeutic while also assessing risk.
Suicide-related scenarios are stressful and emotionally activating for all mental health, school and health care professionals. Counselors are no exception. But counselors bring a different orientation into the room. As a discipline, counseling is less steeped in the medical model, more oriented toward wellness, and more relational throughout the assessment and intervention processes. In this article, we explore how professional counselors can meet practice standards for suicide assessment and treatment while also embracing a holistic, strengths-based and wellness orientation.
Moving beyond traditional views of suicide
Suicide and suicidality have long been linked to negative judgments. Sometimes suicide — or even thinking about suicide — has been characterized as sinful or immoral. In many societies, suicide was historically deigned illegal, and it remains so in some countries today. In the past, suicidality was nearly always pathologized, and that largely remains the case now. Defining suicide and suicidal thoughts as immoral, illegal or as an illness is an alienating and judgmental social construction that makes people less likely to openly discuss these thoughts and feelings. Most people experiencing suicidality already feel bad about themselves;socially sanctioned negative judgments can cause further harm.
Our position is that suicide is neither a moral failure nor evidence of so-called mental illness. Instead, consistent with a strengths-based perspective, we believe that suicidal ideation is a normal variation on human experience. Suicidal ideation usually stems from difficult environmental circumstances, social disconnection or excruciating emotional pain. Improving life circumstances, enhancing social connection and reducing emotional pain are usually the best means for reducing the frequency and intensity of suicidal thoughts and feelings.
Practitioners trained in the medical model tend to diagnose people who are suicidal with some variant of depressive disorder and provide treatments that target suicidality. Sometimes treatments are applied without patient consent. Health care providers are usually considered authority figures who know what’s best for their patients.
In contrast to the medical model, a strengths-based perspective includes several empowering assumptions:
• When painful psychological distress escalates, strengths-based counselors view the emergence of suicidal ideation as a normal and natural human response. Suicidal ideation is a reaction to life circumstances and may represent a method for coping with relentless psychological pain.
• Because suicidal ideation is viewed as a normal response to psychological pain, client disclosures of suicidality are framed as expressions of distress, rather than evidence of illness. Consequently, if clients disclose suicidality, counselors don’t react with fear and judgment, but instead welcome suicide-related disclosures. Strengths-based counselors recognize that when clients openly share suicidal thoughts, they are showing trust, thus creating opportunities for interpersonal and emotional connection.
• Many people who are suicidal want to preserve their right to die by suicide. If they feel judged by health care or school professionals and coerced to receive treatment, they may shut down and resist. Instead of insisting that clients and students “need treatment,” strengths-based counselors recognize that clients are the best experts on their own lived experiences. Strengths-based counselors provide empathic, collaborative assessment and treatment when clients and students who are suicidal.
• Instead of relying on mental health diagnoses or asking symptom-based questions from a standard form such as the Patient Health Questionnaire-9, strengths-based counselors weave in assessment questions and observations pertaining to client strengths, hope and coping resources. Using principles of solution-focused counseling and positive psychology, strengths-based counselors balance symptom questions with wellness-oriented content.
We believe these preceding assumptions can be woven into counseling in ways that improve traditional suicide assessment and treatment approaches. In fact, over the past two decades, evidence-based treatments for suicide, such as collaborative assessment and management of suicide, have increasingly emphasized empathy, normalization of suicidality and counselor-client collaboration. An objectivist philosophy and medical attitude is no longer required to work with clients or students who are suicidal. Newer approaches, including the strengths-based approach discussed here, flow from postmodern, social constructionist philosophy in which conversation and collaboration are fundamental to decreasing distress and increasing hope.
A holistic approach
When clients disclose suicidal ideation, it’s not unusual for counselors to overfocus on assessment. In reaction to suicidality, counselors may begin asking too many closed questions about the presence or absence of suicide risk and protective factors. This shift away from an empathic focus on what’s hurting and toward analytic assessment protocols is unwarranted for two primary reasons. First, based on a meta-analysis of 50 years of risk and protective factors studies, a research group from Vanderbilt, Harvard and Columbia universities concluded that no factors provide much statistical advantage over chance suicide predictions. In other words, even if mental health or school professionals conduct an extensive assessment of client risk and protective factors, that assessment is unlikely to offer clinical or predictive value. Second, focusing too much on suicide risk assessment usually detracts from important relationship-building interactions that are necessary for positive counseling outcomes.
Instead of overemphasizing risk factor assessment, counselors should identify client distress and respond empathically. Recognizing and responding supportively to emotional pain and distress will help individualize your understanding of the client’s unique risk and protective factors. From a practical perspective, rather than using a generic risk factor checklist, counselors are better off directly asking clients questions such as, “What’s happening that makes you feel suicidal?” and “What one thing, if it changed, would take away your suicidal feelings?”
Additionally, as strengths-based practitioners, we should be scanning for, identifying and providing clients feedback on their unique positive qualities. Statements such as “Thank you so much for being brave enough to tell me about your suicidal thoughts” communicate acceptance and a reflection of client strengths. Although counselors may work in settings that use traditional suicide risk assessment protocols, they can still complement that procedure with a more holistic, positive and interpersonally supportive assessment and treatment planning process.
To help counselors tend to the whole person — instead of overfocusing on suicidality — we recommend using a dimensional assessment and treatment model. Our particular dimensional model tracks and organizes client distress into seven categories. Here, we describe each dimension, offer examples of how distress manifests differently within each dimension, and identify evidence-based or theoretically robust interventions that address dimension-specific distress.
The emotional dimension: Clients who are suicidal often experience agonizing levels of sadness, anxiety, guilt, shame, anger and other painful emotions. Other times, clients feel numb or emotionally drained. Focusing on and showing empathy for core emotional distress or numbness is foundational to working with these clients. Clients also may experience emotional dysregulation. Interventions to address emotional issues in counseling include traditional cognitive behavioral therapies for depression and anxiety, existential exploration of the meaning of emotions, and dialectical behavior therapy to aid clients in emotional regulation skill development.
The cognitive dimension: Humans often react to emotional pain with maladaptive cognitions that further increase their distress. Hopelessness, problem-solving impairments and core negative beliefs are linked to suicide. Depending upon each client’s unique cognitive symptoms and distress, strengths-based counselors will begin by responding with empathy and then, if needed, work with hopelessness in the here and now as it emerges in session. Counselors also may initiate problem-solving strategies, emphasize solution-focused exceptions and teach clients how to notice, track and modify maladaptive thoughts.
The interpersonal dimension: Substantial research points to social and interpersonal difficulties as factors that drive people toward suicide. Common interpersonal themes that trigger suicidal distress include social disconnection, interpersonal grief and loss, social skills deficits, and repetitive dysfunctional relationship patterns. Interventions in the interpersonal dimension include couple or family counseling, grief counseling, social skills training, and other strategies for enhancing social and romantic relationships.
The physical dimension: Physical symptoms trigger and exacerbate suicidal states. Common physical symptoms linked to suicide include agitation/arousal, physical illness, physical symptoms related to trauma, and insomnia. Using a strengths-based model, counselors can collaboratively develop treatment plans that directly address physical symptoms. Specific interventions include physical exercise, evidence-based trauma treatments, and cognitive behavior therapy for insomnia.
The cultural-spiritual dimension: Cultural practices and beliefs alleviate or contribute to client distress and suicidality. Religion, spirituality and a sense of purpose or meaning (or a lack thereof) powerfully mediate suicidality. Specific cultural-spiritual themes that trigger distress include disconnection from a community, higher power or faith system. A sense of meaninglessness or acculturative distress may also be present. Strengths-oriented counselors explore the cultural-spiritual and existential issues present in clients’ lives and develop individualized approaches to addressing these deeply personal sources of distress and potential sources of support or relief.
The behavioral dimension: Clients and students sometimes engage in specific behaviors that increase suicide risk. These may include alcohol/drug use, impulsivity and repeated self-injury. Having easy access to guns or other lethal means is another factor that increases risk. Helping clients recognize destructive behavior patterns, develop alternative coping behaviors and decrease their access to lethal means can be central to a holistic treatment plan. Additionally, collaborative safety planning is an evidence-based suicide intervention that focuses on positive coping behaviors.
Contextual dimension: Many larger contextual, environmental or situational factors contribute to distress in the other six dimensions and thus heighten suicidality. These factors include poverty, neighborhood or relationship safety, racism, sexual harassment and unemployment. Helping clients recognize and change contextual life factors — if they have control over those factors — can be very empowering. Clients also need support coping with uncontrollable stressors. Developing an action plan and discerning when to use mindful acceptance may be an important part of the counseling process. Advocacy can be particularly useful for supporting clients as they face systemic barriers and oppression.
Suicide competencies
Regardless of theoretical orientation or professional discipline, mental health and school professionals must meet or exceed foundational competency standards. In this article, we recommend integrating strengths-based principles, holistic assessment and treatment planning, and wellness activities into your work with individuals who are suicidal. Our recommendation isn’t intended to completely replace traditional suicide-related practices, but rather to add strengths-based skills and holistic case formulation to your counseling repertoire.
When adding a strengths-based perspective into your counseling repertoire, it is critical to remain cognizant of the usual and customary professional standards for working with suicide. The American Counseling Association’s current ethics code doesn’t provide specific guidance for suicide assessment and treatment. However, suicide-related competencies are available in the professional literature. For example, Robert Cramer of the University of North Carolina Charlotte distilled 10 essential suicide competencies from several different health care and mental health publications, including guidelines from the American Association of Suicidology.
Cramer’s 10 suicide competencies are listed below, along with short statements describing how strengths-based counselors can address each competency.
1) Be aware of and manage your attitude and reactions to suicide. Strengths-based counselors strive for individual, cultural, interpersonal and spiritual self-awareness. Self-care also helps counselors stay balanced in their emotional responses to clients who are suicidal.
2) Develop and maintain a collaborative, empathic stance with clients. Strengths-based counselors are relational, collaborative and empathic, while also consistently orienting toward clients’ strengths and resources.
3) Know and elicit evidence-based risk and protective factors. Strengths-based counselors understand how to individualize risk and protective factors to fit each client’s unique risk and protective dynamics.
4) Focus on the current plan and intent of suicidal ideation. Strengths-based counselors not only explore client plans and intentions but also actively engage in conversations about alternatives to suicide plans and ask clients about individual factors that reduce intent.
5) Determine the level of risk. Strengths-based counselors engage clients to obtain information about self-perceived risk and collaborate with clients to better understand factors that increase or decrease individual risk.
6) Develop and enact a collaborative evidence-based treatment plan. Strengths-based counselors engage clients in establishing an individualized safety plan that includes positive coping behaviors and collaboratively develop holistic treatment plans that address emotional, cognitive, interpersonal, cultural-spiritual, physical, behavioral and contextual life dimensions.
7) Notify and involve other people. Strengths-based counselors recognize the core importance of interpersonal connection to suicide prevention and involve significant others for safety and treatment purposes.
8) Document risk assessment, the treatment plan and the rationale for clinical decisions. Strengths-based counselors follow accepted practices for documenting their assessment, treatment and decision-making protocols.
9) Know the law concerning suicide. Strengths-based counselors are aware of local and national ethical and legal considerations when working with clients who are suicidal.
10) Engage in debriefing and self-care. Strengths-based counselors regularly consult with colleagues and supervisors and engage in suicide postvention as needed.
The strengths-based approach in action
Liam was a 20-year-old cisgender, heterosexual male with a biracial (white and Latino) cultural identity. At the time of the referral, Liam had just started a vocational training program in the diesel mechanics trade through a local community college. He was referred to counseling by his trade instructor. About a week previously, Liam had experienced a relationship breakup. Subsequently, he punched a wall while in class (breaking one of his fingers), talked about killing himself, threatened his former girlfriend’s new boyfriend, and impulsively walked off the job at his internship placement.
Liam started his first session by bragging about punching the wall. He stated, “I don’t need counseling. I know how to take care of myself.”
Rather than countering Liam’s opening comments, the counselor maintained a positive and accepting stance, saying, “You might be right. Counseling isn’t for everyone. You look like you’re quite good at taking care of yourself.”
Liam shrugged and asked, “What am I supposed to talk about in here anyway?”
Many clients who are feeling suicidal immediately begin talking about their distress. Others, like Liam, deny suicidality. When clients lead with distress, the counselor’s first task is to empathically explore the distress and highlight unique factors in the client’s life that trigger suicidal thoughts and impulses. In contrast, with Liam, the counselor mirrored Liam’s opening attitude, accepted Liam’s explanation and explicitly focused on Liam’s strengths: his employment goals, his initiative to start vocational training immediately after graduating high school, his ability to care deeply for others (such as his ex-girlfriend), and his pride at being physically fit.
After about 15 minutes, the conversation shifted to how Liam made decisions in his life. Instead of questioning Liam’s judgment, the counselor continued a positive focus, saying, “As I think about your situation, in some ways, hitting the wall was a good idea. It’s definitely better than hitting a person.” The counselor then added, “I don’t blame you for being pissed off about breaking up. Nobody likes a breakup.”
The counselor asked Liam to tell the story of his relationship and the events leading to the breakup. Liam was able to talk about his sense of betrayal and loneliness and his underlying worries that he’d never accomplish anything in life. He admitted to occasional thoughts of “doing something stupid, like offing myself.” He agreed to continue with counseling, mostly because it would look good to his vocational training instructor. Before the session ended, the counselor explained that counselors always need to do a thing called “a safety plan.” During safety planning, Liam admitted to owning two firearms, and even though he “didn’t need to,” he agreed to store his guns at his mom’s house for the next month.
After the first session, the counselor documented the assessment, the intervention and Liam’s treatment plan. The counselor’s documentation included problems and strengths, organized with the holistic dimensional model:
1) Emotional: Liam experienced acute emotional distress and emerging suicidal ideation related to a relationship breakup. Although he minimized his distress, Liam also was able to articulate feelings of betrayal and loneliness.
2) Cognitive: Liam felt hopeless about finding another girlfriend. He was somewhat evasive when asked about suicidal ideation. Eventually, he acknowledged thinking about it and that if he ever decided to die (which he said he “wouldn’t”), he would shoot himself. Liam was able to participate in problem-solving during the session.
3) Interpersonal: Although Liam was distressed about the breakup of his romantic relationship, he agreed to consult with his counselor about relationships during future sessions. He collaboratively brainstormed positive and supportive people to contact in case he began feeling lonely or suicidal. Liam reported a positive relationship with his mother.
4) Physical: Liam reported difficulty sleeping. He said, “I’ve been drinking more than I need to.” During safety planning, Liam agreed to specific steps for dealing with his insomnia and alcohol consumption. Liam was in good physical shape and was invested in his physical well-being.
5) Cultural-spiritual: Liam said that “it won’t hurt me any” to attend church with his mom on Sundays. He reported a good relationship with his mother. He said that going to church with her was something she enjoyed and something he felt good about.
6) Behavioral: Liam contributed to writing up his safety plan. He agreed to follow the plan and take good care of himself over the coming week. Liam identified specific behavioral alternatives to drinking alcohol and suicidal actions. He agreed to store his firearms at his mother’s home.
7) Contextual: Other than high unemployment rates in his community, Liam didn’t report problems in the contextual dimension. He said that he currently had an apartment and believed he had a good employment future.
Concluding comments
A holistic, strengths-based and wellness-oriented model for working with clients and students who are suicidal is a good fit for the counseling profession. In tandem with knowledge and expertise in traditional suicide assessment and treatments, the strengths-based model provides a foundation for suicide assessment and treatment planning. A detailed description of the strengths-based model is available in our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach, which was published earlier this year by the American Counseling Association.
BIO BOX
John Sommers-Flanagan is professor of counseling at the University of Montana with over 100 professional publications, including Clinical Interviewing, Suicide Assessment and Treatment Planning, and seven other books coauthored with Rita. You can contact him via email (john.sf@mso.umt.edu) or through his blog, where you can also access free counseling-related resources (https://johnsommersflanagan.com/)
Rita Sommers-Flanagan is professor emerita of counseling at the University of Montana. After retiring, Rita has shifted her interests toward suicide prevention, positive psychology, creative writing and passive solar design. She blogs at: https://godcomesby.com/author/ritasf13/ and her email address is rita.sf@mso.umt.edu.
Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.
Here’s a glimpse of what the garden looks like this morning.
In most of life, most of the time, there’s not much completely new or original. People tend to gather inspiration from others and build on or rediscover old ideas. This my way of acknowledging that, although I wish I always had a boatload of original ideas to share in the blog, more often than not, I’m embracing the green new deal and . . . re-using, recycling, and repurposing old ideas.
The following Table describes the seven dimension model that Rita and I use to aid clinicians in conducting assessments and interventions with clients or patients who are suicidal. These seven dimensions aren’t original, but the idea that suicide drivers (and risk/protective factors) can emerge and influence people from any or all of these dimensions is helpful in a more or less original way. Check out the Table to see if it’s useful for you.
Dimension:In this column, we define the dimensions
Evidence-Based Suicide Drivers: In this column, we identify risk factors or suicide drivers that can push or pull individuals toward suicidality. The key to this model is to identify and treat the main sources of distress (aka psychache). In the next columns (not included here), you would find wellness goals and specific interventions.
Emotional: all human emotions.
Excruciating emotional distress
Specific disturbing emotions (guilt, shame, anger, sadness)
Emotional dysregulation
Cognitive: All forms of human thought, including imagery.
Hopelessness
Problem-solving impairments
Maladaptive thoughts
Negative core beliefs
Interpersonal: All human relationships.
Social disconnection and perceived burdensomeness
Interpersonal loss and grief
Social skill deficits
Repeating dysfunctional relationship patterns
Physical: All human biogenetics and physiology.
Biogenetic predispositions and physical illness
Sedentary lifestyle; poor nutrition
Agitation, arousal, anxiety
Trauma, nightmares, insomnia
Spiritual-Cultural: All religious, spiritual, cultural values that provide meaning and purpose.
Religious or spiritual disconnection
Cultural disconnection or dislocation
Meaninglessness
Behavioral: All human action and activity.
Using substances or self-harm for desensitization
Suicide planning, intent, and preparation
Impulsivity
Contextual: All factors outside of the individual that influence human behavior.
No connection to place or nature
Chronic exposure to unhealthy environmental conditions
Socioeconomic oppression or resource scarcity (e.g., poverty)
In partnership with Montana Pediatrics and the Nate Chute Suicide Prevention Foundation, the Montana Happiness Project is launching its “Geographically Exclusive” strengths-based suicide assessment and treatment planning workshop series. The purpose of this workshop series is to work with mental health and school counselors from specific geographic regions to further develop community-based professional competence in suicide assessment, treatment planning, and intervention. Our goal is to train professionals to provide excellent care to students, clients, and patients who are experiencing suicidality. At the same time, similar to Dr. Marsha Linehan’s dialectical behavior therapy model, we hope to build professional communities that will support one another in facing this challenging and stressful professional activity. We believe that if practitioners within a single community feel more competent AND more supported, they’ll be able to be more effective, more available, and better able to handle the stress associated with suicide assessment and intervention work.
Our first geographically exclusive workshop is scheduled for two consecutive Tuesday evenings: April 13 and 20 from 4:15pm-7:15pm. Here’s the description:
Interested in learning a new approach to suicide assessment and treatment? John Sommers-Flanagan, professor of counseling at the University of Montana, will be leading an innovative professional development opportunity on strengths-based suicide prevention.
Founded on current research and national best-practices, this workshop will help you: Understand the limits of suicide risk factor assessment
Use creative approaches to connect with distressed clients, while collecting useful assessment information
Respond compassionately and effectively to client hopelessness, irritability, passive suicidality, and more
Initiate collaborative safety and treatment planning protocols
If you’re interested in hosting a geographically exclusive suicide workshop in your region (via Zoom or in-person), please email me at john.sf@mso.umt.edu
Earlier today I had a 90-minute Zoom meeting with the staff from Bridgercare of Bozeman, Montana. Bridgercare is a medical clinic focusing on sexual and reproductive health. Our meeting’s purpose was to provide staff with training on how to integrate a strengths-based approach to suicide assessment and treatment into their usual patient care.
It’s probably no big surprise to hear this, but even through Zoom, the Bridgercare staff was fabulous. They’re clearly dedicated to the safety and wellbeing of their patients. I enjoyed meeting them and wish I could have been there live and in-person (but, having gotten my second vaccine shot today, more live and in-person events are in my future!).
One member of the medical staff asked if I had material on how to enhance the safety planning process with patients. After fumbling the question for a while, I remembered that I included a safety planning case example in Chapter 8 of our suicide book. I’ve included the excerpt below. Although the case is written in my voice, as you read through, think about how you might put it into your voice.
This case description illustrates a positive working relationship and outcome. Just to make sure you know that I’m not too Pollyannaish about suicide-related work, the whole book also includes cases and situations with less positive scenarios and outcomes.
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Below, the counselor is discussing a safety plan with a 21-year-old cisgender female college senior named Kayla. Kayla was attending a large state university and living off campus in a small apartment. In this case, Kayla was social distancing in compliance with state stay-at-home orders; the session was conducted remotely, via an online video-based HIPAA-compliant platform (e.g., Doxy.me, SimplePractice, etc.).
The Opening and Unique Suicide Warning Signs
Counselor: Kayla, I’m putting your name on the top of this form [holds form up to camera]. It’s called a safety planning form. Some very smart people made up this form to help people stay safe. There are six questions. We’re supposed to fill it out together. If you hate it when we’re done, we can toss it in the trash. Okay?
Kayla: Okay. That’s possible.
Counselor: That would be fine. Here’s the first question. I’m just going to read them to you. Then you answer, I’ll write down your answers, and then we talk about your answer. What are the signs, in yourself or in your environment that will be a warning that tells you that you need to do something to keep yourself safe?
Kayla: I just like feel a wave of sadness and defeat. Like my life means nothing. Like I’m a damaged, bad person who should die.
Counselor: Okay. A wave of sadness and defeat. How will you know that wave has come? What do you feel in your body or think in your brain?
Kayla: I feel a physical ache. I think about being abused. I think horrible thoughts.
Counselor: I’m writing down, “Wave of sadness and defeat, and physical ache, and thoughts of being damaged, bad, and abused.” Those are all signs that you should follow this safety plan.
Kayla: Also, being home alone at night.
In this initial exchange the counselor empowers Kayla to reject the plan if she wants to. Offering to let Kayla reject the plan probably makes it more likely for her to take ownership of the plan. If Kayla ends up rejecting the plan, that information becomes part of the overall assessment and guides treatment decision-making.
Kayla immediately engages in the process. Specifically, her trauma-based thoughts of being damaged and bad could be fruitful therapeutic grist for cognitive processing therapy or EMDR, both of which address trauma and focus on beliefs about the self. However, when using the SPI, it’s best to stay focused on the SPI, and save the deeper therapeutic content for later. The counselor could (and should) have said, “For now, we’re working on this plan. But later on, if you want, we can start working on your feelings of being damaged and bad.”
Personal Coping Strategies
Counselor: What can you do in the moment to cope with suicidal thoughts and feelings?
Kayla: Look. I could cut myself to feel better, but nobody wants me to do that.
Counselor: I’m sure it’s true that people don’t want you cutting. I also think it’s true that people would rather have you cut yourself than kill yourself. If cutting keeps you alive, we should put it in the plan, at least for now.
Kayla: I think it should be there then.
Counselor: Okay. So, cutting goes on here as a method for calming or soothing yourself. Have I got that right?
Kayla: Yeah. It calms me down when I’m upset.
Counselor: What else could calm you down or distract you from suicidal thoughts?
Kayla: I could listen to music or call a friend.
Counselor: Great. I’m writing those ideas into the plan right now.
Brainstorming coping responses is similar to other processes discussed in chapter 5 (problem-solving and alternatives to suicide). One key principle is to accept all responses before evaluating them later. In the preceding interaction, the counselor accepts that cutting might be a viable (even if not preferred) short-term coping strategy, and then continues to nudge Kayla to generate additional coping ideas. Although cutting isn’t addressed in this case example, after developing the safety plan, therapeutic conversations about cutting and alternatives to cutting, should become a part of ongoing counseling (see Kress et al., 2008; Stargell et al., 2017).
Social Contacts and Settings
Counselor: I’m wondering about those times when you’re alone. Who could you be with to stay safe? Even if it’s only for you to distract yourself?
Kayla: I have a friend named Monroe. He’s crazy. He’s always happy. Sometimes he annoys me, but he’s a good distraction.
Counselor: Monroe sounds like a great distraction. He’s in the plan. Are you able to see him in person, or would you do Facetime or a Zoom call.
Kayla: He lives in the apartment building and we could meet up outside.
Counselor: That sounds great. Who else?
Kayla: I can always call my parents, but when I do, I feel like failure. I’m an adult.
Counselor: If you’re feeling suicidal, would your parents want you to call?
Kayla: Yeah.
Counselor: Okay then. Let’s put your parents down. We can talk more later about how calling them might make you feel.
The counselor does a good job of getting Kayla to be specific about how she could connect with Monroe. Overall, Kayla doesn’t have an extensive social support network. Expanding that network will likely become an important goal for counseling.
People Whom I Can Ask Help
Counselor: This question is similar to the last one, but a little different. Instead of people who are distracting, now I’m wondering who you can turn to if you’re in crisis?
Kayla: Monroe wouldn’t be the right person for that.
Counselor: Not Monroe. But who would be right for that?
Kayla: My parents, I guess. And my aunt, Sarah. She’s always been there for me. I could call her if I need to. And my grandma.
Counselor: Good. That’s four. Your mom, your dad, your aunt Sarah, and your grandma. Are they around here, or would you call or text them?
Kayla: My parents and aunt live close by, but we’d probably just Facetime because they’re older I don’t want them to get COVID. My grandma lives in Minnesota.
While generating lists, it’s useful to draw clients into being even more specific than illustrated in this exchange. For example, as Kayla identifies people to call, getting specific about texting or calling, where the person might be, and what to do if there’s no answer, is good practice. Role playing a call or text can be useful, because rehearsing behaviors make them more likely to occur.
Mental Health Professionals or Agencies to Contact
Counselor: How about professionals or agencies that you can call if you’re in a crisis?
Kayla: I don’t have anyone.
Counselor: Wait. You need to put me here. I should be on the list. I can be available for short calls Sunday through Thursday evenings up until 9pm.
Kayla: Okay.
Counselor: And there’s 9-1-1, right? You can always call 9-1-1. In an emergency, that’s what you do. There’s also a new suicide hotline number, 9-8-8. I’m going to write that number down too. You don’t have to call any number, but it’s good to have them just in case you do want to call for professional help during a crisis. The other thing to remember about calling hotlines is that you may get someone you don’t like or don’t connect with. If that happens, keep trying, but also, jot down a few notes so you can tell me about it.
In the preceding exchange, the counselor offers to be a limited option. Whether you provide a personal contact number is up to you. Whatever you do, spell it out in your informed consent and have boundaries around the times when communications with you are acceptable. Because calling hotlines may or may not feel helpful, empowering Kayla to critique her hotline experience and then report it to the counselor might increase her willingness to call.
How Can I Make My Environment Safe?
Counselor: This last question has to do with how you can make your environment safe. We’ve talked about various things, like how you can cope and who you can call. Now we need to talk about whether there’s anything dangerous in your home, anything that could be used to kill yourself if you were suddenly suicidal.
Kayla: Yeah. Well I bought a hand-gun last year. That’s how I would do it.
Counselor: Right. Thanks for telling me about the gun. Can I just tell you what I’m thinking right now?
Kayla: Sure.
Counselor: With guns and suicide, there are two good options. One is for you to give it to someone for now, until you’re feeling better. The other is for you to safely store the gun or get a trigger lock. I’m just being totally honest with you about this. The reason we should get your gun locked up or given to your parents or someone else, is because most of the time, people are intensely suicidal for only 5 or 10 or maybe 30 minutes. During that intense time, people can do things they later regret. Most people who make a suicide attempt don’t make another attempt. It’s usually a one-time thing. My main goal is for you to be safe.
Kayla: But I’m not planning to use the gun or anything.
Counselor: Right. That’s great. But let’s say your Aunt Sarah was suicidal and she had a gun, would you be willing to keep it for her if it made her safer?
Kayla: Of course I would.
Counselor: So, whether it’s you or your Aunt Sarah, we want to make sure suicide doesn’t happen because of one terrible moment.
The preceding is an example of psychoeducation around suicidality and safety planning. If you have a good rapport and connection with your client, the psychoeducation is likely to be well-received. If your rapport and connection is less good, then you’ll either need to work on the relationship, or take a more directive and authoritative role to promote your client’s safety.
Counselor: All right. I’ve written down your ideas for the safety plan. Now, I’m going to scan it and send it to you through our secure portal. As we’ve already discussed, we’re going to make a bigger plan for your counseling. But in the meantime, we need to keep you safe so we can do the counseling. Right now, you’ve got this safety plan you can use, and we can revise it if we need to. Okay?
Kayla: Okay.
Counselor: Kayla, thank you very much for working with me on this safety plan. I think we made a good plan together.
Kayla: Me too. I guess I won’t throw it in the trash.
Counselor: You’re pretty funny.
Please excuse any typos or bad grammar. The preceding is a pre-published (and pre-copyedited) version from my computer. To check out and possibly purchase the whole darn book, you can go here: https://imis.counseling.org/store/detail.aspx?id=78174
Working with suicidal clients often involves working two sides at the same time. . . as in a dialectic or paradox. For example, it’s crucial to be able to move back and forth between empathic acceptance and active-collaborative problem-solving.
When working from a strengths-based model, clinicians shouldn’t shy away from focusing on pain, sadness, anger, or other aversive emotions and experiences. At the same time, we need to also focus on potential strengths. The following excerpt from our new suicide book illustrates how to explore previous attempts, while also looking for strengths.
Previous attempts are often considered the most significant suicide predictor (Brown et al., 2020; Fowler, 2012). You can gather information about previous attempts through your client’s medical or mental health records, from an intake form, or during the clinical interview. During clinical interviews, clients may spontaneously tell you about previous attempts; other times you’ll need to ask directly. Again, using a normalizing frame can be facilitative:
It’s not unusual for people who are feeling very down to have made a suicide attempt. I’m wondering if there have been times when you were so down that you tried to kill yourself?
Once you have knowledge about a client’s previous suicide attempt, you can explore several dimensions of the attempt:
What was happening that made you want to end your life?
When you discovered that your suicide attempt failed, what thoughts and feelings did you experience?
Some people report learning something important from attempting suicide. Did you learn anything important? If so, what did you learn?
Although the preceding questions are important for assessment, once you’re ready to move beyond exploration of a previous attempt, you should ask a therapeutic solution-focused question, similar to the following:
You’ve tried suicide before, but you’re here with me now . . . what has helped? (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 373).
Asking “What helped?” is central to a strength-based or solution-focused model and sometimes illuminates a path forward toward living. However, if your client is depressed, you may hear,
In the context of an assessment protocol, the “What helped?” question and its side-kick, “What have you tried?” are important because they assess for two core cognitive problems associated with suicidality: hopelessness and problem-solving impairment. Clients who respond with “nothing ever helps” are communicating hopelessness. Clients who claim, “I’ve tried everything” or “There’s nothing left to do” are communicating hopelessness, plus the narrowing of cognitive problem-solving that Shneidman (1996) called mental constriction. Hopelessness and problem-solving impairments should be integrated into your suicide treatment plan.
You can read more excerpts of our book in other posts on this blog, via Amazon or Google. You can also purchase it as an eBook through Wiley, Amazon, or as a paperback through the American Counseling Association: https://imis.counseling.org/store/detail.aspx?id=78174
Because I’ve been getting plenty of questions about the Strengths-Based Approach as applied to suicide assessment and treatment, I’m re-posting a revised version of this blog from June, 2020. My apologies for the redundancy. On the other hand, as a friend and mental health professional has repeatedly told me, “Redundancy works.” So . . . I guess his redundancy worked on me.
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.
Just a heads up. I’ll be writing several posts about our new book this week. Be forewarned, these posts may be annoying. Annoying can happen when people feel enthusiastic. My apologies in advance.
In response to these upcoming posts from me (or annoying posts from others), you can apply one of three strategies.
You can respond with positive affirmation, sharing, and by empathically matching my enthusiasm. Keep in mind that positive affirmation may make me happy. The downside is you risk reinforcing my “new book posting” behavior.
You can respond with no response. That was a favored B.F. Skinner and Ivan Pavlov strategy. Think of it as putting me on a pain-free extinction schedule.
You can respond with negativity or punishment. Skinner, Adler, and child advocates oppose punishment, because punishment can backfire, causing undesired behavior to increase, or triggering erratic behaviors.
True confession: When reading offensive or annoying posts, sometimes, even though I know better, I give into temptation, and respond with negativity. That’s nearly always a bad idea, mostly because option #3 of the preceding list is a poor extinction strategy. In one recent study, when social media posts received highere numbers of negative responses, the original social media posters responded back with even more posts. In other words, attention—even negative attention—acts as positive reinforcement and often increases the behavior toward which it was aimed. The take-home message is that, generally speaking, if you want to extinguish annoying blog posting behavior, following Skinner’s and Pavlov’s advice makes for good behavioral strategy.
Although I’m wary of the possibility of you all putting me on an extinction schedule, below is an excerpt from the Preface of our fancy new book. Right now the book is only available on the publisher’s website (https://imis.counseling.org/store/detail.aspx?id=78174), but I suspect it will soon make its way over to Amazon and the rest of the booksellers.
Preface
Writing a book about suicide may not have been our best idea ever. Rita made the point more than once that reading and writing about suicide at the depth necessary to write a helpful book can affect one’s mood in a downward direction. She was right, of course. Her rightness inspired us to pay attention to the other side of the coin, so we decided to integrate positive psychology and the happiness literature into this book. As is often the case when grappling with matters of humanity, focusing on suicide led us to a deeper understanding of suicide’s complementary dialectic, a meaningful and fully-lived life, and that has been a very good thing.
Before diving into these pages, please consider the following.
Do the Self-Care Thing
In the first chapter, we strongly emphasize how important it is to practice self-care when working with clients who are suicidal. Immersing ourselves in the suicide literature required a balancing focus on positive psychology and wellness. While you’re reading this book and exploring suicide, you cannot help but be emotionally impacted, and we cannot overstate the importance of you taking care of yourself throughout this process and into the future. You are the instrument through which you provide care for others . . . and so we highly encourage you to repeatedly do the self-care thing.
What is the Strengths-Based Approach?
Many people have asked, “What on earth do you mean by a strengths-based approach to suicide assessment and treatment planning?” In response, we usually meander in and out of various bullet points, relational dynamics, assessment procedures, and try to emphasize that the approach is more than just strengths-based, it’s also wellness-oriented and holistic. By strengths-based, we mean that we recognize and nurture the existing and potential strengths of our clients. By wellness-oriented we mean that we believe in incorporating wellness activities into counseling and life. By holistic we mean that we focus on emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual dimensions of living.
You will find the following strengths-based, wellness-oriented, and holistic principles woven into every chapter of this book.
Historically, suicide ideation has been socially constructed as sinful, illegal, or a terribly frightening and bad illness. In contrast, we believe suicide ideation is a normal variation on human experience that typically stems from difficult environmental circumstances and excruciating emotional pain. Rather than fear client disclosures of suicidality, we welcome these disclosures because they offer an opportunity to connect deeply with distressed clients and provide therapeutic support.
Although we believe risk factors, warning signs, protective factors, and suicide assessment instruments are important, we value relationship connections with clients over predictive formulae and technical procedures.
We believe trust, empathy, collaboration, and rapport will improve the reliability, validity, and utility of data gathered during assessments. Consequently, we embrace the principles of therapeutic assessment.
We believe that counseling practitioners need to ask directly about and explore suicide ideation using a normalizing frame or other sophisticated and empathic interviewing strategies.
We believe traditional approaches to suicide assessment and treatment are excessively oriented toward psychopathology. To compensate for this pathology-orientation, we explicitly value and ask about clients’ positive experiences, personal strengths, and coping strategies.
We believe the narrow pursuit of psychopathology causes clinicians to neglect a more complete assessment and case formulation of the whole person. To compensate, we use a holistic, seven-dimensional model to create a broader understanding of what’s hurting and what’s helping in each individual client’s life.
We value the positive emphasis of safety planning and coping skills development over the negative components of no-suicide contracts and efforts to eliminate suicidal thoughts.
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John Sommers-Flanagan 