Tag Archives: depression

Happiness, Love, Parenting, Personal Reflections, Writing

Tomorrow’s Presentation at the Montana CASA Conference in Butte

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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.

  1. 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.
  2. Three ways your brain works. [This one thing has three parts. Woohoo.]
    1. 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.
    1. We find what we’re looking for. This is called confirmation bias, which I’ve blogged about before.
    1. 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?).
  3. We’re NOT GOOD at shrinking NEGATIVE behaviors. This is so obvious that my therapist friends usually say, “Duh” when I mention it.
  4. 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.
  5. Should we focus on happiness? The answer to this is NO! Too much preoccupation with our own happiness generally backfires.
  6. 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].”
  7. You can flip the happiness. This thing flows from a live activity. To get it well, you’ll need to be there!
  8. 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.
  9. 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.
  10.  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.

For those interested, here’s the slide deck:

Ten Things CASA Sept 2025Download

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!

Personal Reflections, Writing

Hope Theory for Suicide Prevention Month on the Blackfeet Reservation

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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.

Here they are on Facebook: https://www.facebook.com/watch/?v=9232983300123005

And Instagram: https://www.instagram.com/reel/DIjQIhtirRj/

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:

I hope you’ll watch and share this video.

Here’s the link on the Firekeeper Alliance website: https://firekeeperalliance.org/news/what-gives-you-hope

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.

Happiness, Love, Personal Reflections, Writing

Come Join Us in Early August in Billings Montana for a Workshop on Happiness for Educators

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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:

2025 Flyer_J BullockDownload

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 hope to see you there.

Clinical Interviewing, Happiness, Personal Reflections, Research, Suicide Assessment and Intervention

Why I’m Mostly Against Universal Suicide Screenings in Schools

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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.

  1. 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.
  2. 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.
  3. 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.
  4. About 10-15% of people who complete suicide screenings feel worse afterward. We don’t really want that outcome.
  5. 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).

And here’s the link to the commentary:

Empathy and Compassion in AP with MRATD 2024Download
Happiness, Research, Writing

Here’s a new article published in The Conversation

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Happiness class is helping clinically depressed school teachers become emotionally healthy − with a cheery assist from Aristotle

This course is more than just suggesting that you ‘cheer up’ and ‘look on the bright side.’ akinbostanci/E+ via Getty Images

John Sommers-Flanagan, University of Montana

Text saying: Uncommon Courses, from The Conversation

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.

All the while, I watched in dismay as U.S. suicide rates relentlessly increased for 20 consecutive years, from 1999 to 2018, followed by a slight dip during the COVID-19 pandemic, and then a rise in 2021 and 2022 – this despite more local, state and national suicide prevention programming than ever.

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.

Why is this course relevant now?

Teachers are more distressed than ever before. They’re anxious, depressed and discouraged in ways that adversely affect their ability to teach effectively, which is one reason why so many of them leave the profession after a short period of time. It’s not just the low pay – educators need support, appreciation and coping tools; they also need to know they’re not alone. https://www.youtube.com/embed/ZOGAp9dw8Ac?wmode=transparent&start=0 This exercise helps you focus on what goes right, rather than the things that go wrong.

What’s a critical lesson from the course?

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.

This improvement is similar to the results obtained by antidepressant medications and psychotherapy.

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.

John Sommers-Flanagan, Clinical Psychologist and Professor of Counseling, University of Montana

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, culture, diversity, Happiness, Suicide Assessment and Intervention

Coming Soon: Maryland’s 36th Annual Suicide Prevention Conference

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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.

Happiness, Research, Writing

The Happy Workshop for Graduate Students Pub: Hot off the Digital Press

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Good news. Yesterday, I got a mysterious email from ORCID–which stands for: Open Researcher and Contributor ID. ORCID is a global, non-profit organization. Their vision is: “a world where all who participate in research, scholarship, and innovation are uniquely identified and connected to their contributions across disciplines, borders, and time.”

Cool.

Anyway, ORCID was notifying me of a change to my ORCID record. A few minutes later, I received an email from Wiley telling me that our Happy Workshop for Grad Students article was now officially published online.

As some of you know, I’ve complained about the journal publishing process, and, although I still think it’s a pretty broken and disturbing process, working with the editors and reviewers from the Journal of Humanistic Counseling was pretty smooth and pretty fabulous. Check them out: https://onlinelibrary.wiley.com/journal/21611939

And so, without further ado, here’s the Abstract, followed by methods to access the article. . .

Effects of a Single-Session, Online, Experiential Happiness Workshop on

Graduate Student Mental Health and Wellness

John Sommers-Flanagan

Jayna Mumbauer-Pisano

Daniel Salois

Kristen Byrne

Abstract

Graduate students regularly experience anxiety, sleep disturbances, and depression, but little research exists on how to support their mental health. We evaluated the effects of a single-session, online, synchronous, happiness workshop on graduate student well-being, mental health, and physical health. Forty-five students participated in a quasi-experimental study. Students attended a synchronous 2.5-h online happiness workshop, or a no-workshop control condition. After workshop completion and as compared with no-treatment controls, participants reported significant reductions in depression symptoms but no significant changes on seven other measures. At 6 months, participants reported further reductions in depression symptoms. Moreover, across four open-ended questions, 37.0%–48.1% of workshop participants (a) recalled workshop tools, (b) found them useful, (c) had been practicing them regularly, and (d) used them in sessions with clients. Despite study limitations, single-session, synchronous, online, happiness workshops may have salutatory effects on graduate student mental health. Additional research is needed.

K E Y W O R D S: depression, graduate students, mental health, single-session, wellness

Here’s a link to the article online: https://onlinelibrary.wiley.com/share/author/UMKTTSPPECBTVXEQYRKX?target=10.1002/johc.12223

And here’s a pdf copy for your personal (non-commercial) use:

happiness-workshop-2024Download
Clinical Interviewing, Suicide Assessment and Intervention

To Hospitalize or Not to Hospitalize? A Suicide Assessment Conundrum

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Yesterday I had a chance to do a 3-hour online workshop with a very cool group of about 22 smart, skilled, and dedicated professionals. They engaged with the content and consequently, we had some great discussions. One of the discussions has kept percolating for me today. The topic: How do we handle situations where clients are clearly suicidal, but are reluctant or unwilling to develop and agree to a collaborative safety plan.  

We talked about how, often, the knee-jerk impulse is to pursue hospitalization. While that’s a viable and reasonable option, the problem is that hospitalization and discharge is a notable risk factor for death by suicide. The other problem is that it’s pretty much impossible for us to know if the client’s resistance to a safety plan indicates increased risk, or just resistance to what s/he/they view as a coercive mandate.

There’s no perfect clinician response to this dilemma. Hospitalization helps some clients, and causes demoralization and regression in others. Not hospitalizing can feel too risky for practitioners.

We talked about a few guidelines in dealing with this conundrum. They include: (a) consulting with colleagues, (b) reflecting on the client’s engagement in other aspects of treatment (increased engagement in treatment is a protective factor), (c) evaluating client intent and client impulsivity, and (d) documenting your decision-making process (including citations indicating that psychiatric hospitalization may not be the best alternative). But again, there’s no perfect guideline.

Below is an excerpt from a CEU course I wrote about a year ago. For the whole CEU (actually there are two different CE courses), you can check out this link: https://www.continuingedcourses.net/active/courses/course114.php

Similar content is also in our brand new Clinical Interviewing textbook: https://www.wiley.com/en-cn/Clinical+Interviewing%2C+7th+Edition-p-9781119981992

Here’s the CEU excerpt:

Decision-Making Dilemmas

When discussing Kate’s situation and other scenarios that involve outpatient work with highly suicidal clients, the following question usually comes up, “What if your judgment is wrong and she either makes a suicide attempt, or she kills herself before your next session?” This is a great question and gets to the core of practitioner anxiety.

The answer is that, yes, she could kill herself, and if she does, I’ll feel terrible about my clinical judgment. Also, I might get sued. And, if I’m inclined toward suicidal thoughts myself, Kate killing herself might precipitate a suicidal crisis in me. Sometimes suicide tragedies happen, and sometimes we will feel like the tragedy was our fault and that we should have or could have prevented it. That said, most suicides are more or less unpredictable. Even if you think you’re correct in categorizing someone as high or low risk, chances are you’ll be wrong; many high-risk clients don’t die by suicide and some low-risk clients do (see Sommers-Flanagan, 2021, for a personal essay on coping with the death of a client to suicide; https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility).

More depressing is the reality that hospitalization – the main therapeutic option we turn to when clients are highly suicidal – isn’t very effective at treating suicidality and preventing suicide (Large & Kapur, 2018). Hospitalization sometimes causes clients to regress and destabilize, and suicide risk is often higher after hospitalization (Kessler et al., 2020). Because hospitalization isn’t a good fit for many clients who are suicidal and because we can’t predict suicide very well anyway, some cutting edge suicide researchers recommend intensive safety planning as a viable (and often preferred) alternative to hospitalization. In the case of Kate, as long as she’s willing to collaborate, and I’m able to contact her husband, and we can construct a plan that provides safety, then I’m on solid professional ground (or at least as solid as professional ground gets when working with highly suicidal clients).

Kessler, R. C., Bossarte, R. M., Luedtke, A., Zaslavsky, A. M., & Zubizarreta, J. R. (2020). Suicide prediction models: A critical review of recent research with recommendations for the way forward. Molecular Psychiatry, 25(1), 168-179. doi:http://dx.doi.org/10.1038/s41380-019-0531-0

Large, M. M., & Kapur, N. (2018). Psychiatric hospitalisation and the risk of suicide. The British Journal of Psychiatry, 212(5), 269-273.

Sommers-Flanagan, J. (2021, July/August). The myth of infallibility: A therapist comes to terms with a client suicide. Psychotherapy Networker. https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility

And here’s an excerpt from Clinical Interviewing.

Collaborate with Clients Who Are Suicidal

The idea that healthcare professionals must take an authoritarian role when evaluating and treating suicidal clients has proven problematic (Konrad & Jobes, 2011). Authoritarian clinicians can activate oppositional or resistant behaviors (Miller & Rollnick, 2013). If you try arguing clients out of suicidal thoughts and impulses, they may shut down and become less open.

For decades, no-suicide contracts were a standard practice for suicide prevention and intervention (Drye et al., 1973). These contracts consisted of signed statements such as: “I promise not to commit suicide between my medical appointments.” In a fascinating turn of events, during the 1990s, no-suicide contracts came under fire as (a) coercive and (b) as focusing more on practitioner liability than client well-being (Edwards & Sachmann, 2010; Rudd et al., 2006). Suicide experts no longer advocate using no-suicide contracts.

Instead, collaborative approaches to working with suicidal clients are strongly recommended. One such approach is the collaborative assessment and management of suicide (CAMS; Jobes, 2016). CAMS emphasizes suicide assessment and intervention as a humane encounter honoring clients as experts regarding their suicidal thoughts, feelings, and situation. Jobes and colleagues (2007) wrote:

CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts.” (p. 285)

Happiness, Personal Reflections, Writing

Dance it Off – Moving for Happiness

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I’m a big fan of exercise and movement as a solution for nearly everything. Below is my famous or infamous “Last Dance” video that I filmed after a day when I got beat up pretty bad by all things Moodle, Powerpoint, and Qualtrics. My solution was to Dance it off, which I share with you all despite the fact that this is the sort of thing one should keep private.

I share this video as a challenge to anyone who feels inclined to make their own 1 minute dance-it-off video. Yes please! And share.

[Unless you read this blog regularly] you may be surprised to hear that exercise is more effective in treating depression than antidepressant medications. If so, that’s likely because pharmaceutical companies spend millions every year to tell you their antidepressants are effective. The marketing budget for exercise as a treatment for depression is considerably less.

Movement—along with sleep and a healthy diet—is probably the best way to keep your brain healthy. Nearly all movement helps. In my favorite exercise study on treating depression in youth, preteens and teens who were depressed had a 100% response to cardio (including Jazzercise and Wii) and a 67% response with just stretching. Exercise does so many good things for the brain that it’s hard to track. Also, other than sweat, thirst, and sore muscles, exercise has no real negative side effects—which isn’t the case for medications.

In conclusion, the researchers wrote:

“Compared to antidepressant medication treatment with adolescents, exercise resulted in (a) a faster response rate, (b) a better response rate, (c) fewer relapses (n = 0) at six and 12 month follow-ups, and (d) no side effects or adverse events” (Hughes et al., 2013). One caveat, at the beginning of the study, none of the participants were exercising.

But who were these researchers? Were they anti-drug researchers with an axe to grind?

Nope, and this is my favorite part. The researchers were prestigious academics who mostly do pharmaceutical research. One of them was the guy responsible for the clinical studies that led to FDA approval of Prozac for treating youth with depression. The two biggest names on the study have repeatedly been funded by Eli Lilly, GlaxoSmithKline, Pfizer, and more.

All this leads me to this week’s #MHPHappinessChallenge assignment.

Find your preferred way to move, pair it with your favorite music, and do what the researchers in the Hughes (2013) study did to treat depression. I call this “Dance it off,” because dancing—alone or together—is a fabulous way to make the time fly by while you give your brain a dose of what it’s craving.

Here’s the Hughes et al (2013) study. I’m sharing it because everyone should know about it:

date-exercise-study-2013Download

But you don’t have to dance. You can walk, run, skip, or yoga. You can jump rope, do Wii or Jazzercize, kickbox, or just jiggle your body in the kitchen while you’re cooking. If you ride the elevator, take the stairs. If you’re in a chair, dance with whatever parts of your body that will move. Of course, don’t do anything that’s so excessive that you might hurt yourself.

I’m sure you get the point.

And then, if you feel something-maybe a high or a fun new thought or anything that kicks your mood up a notch, savor it, linger, and then share it with us.

As always, thanks for participating in the Montana Happiness Challenge. Let’s dance it off together this week.

Parenting, Personal Reflections, Tough Kids Cool Counseling

Interested in Exercise for Treating Depression in Adolescents? Check out the DATE study!

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Half Marathon 2019

Common sense, clinical intuition, non-experimental research studies, and most sentient beings all support the likelihood that physical exercise can reduce depressive symptoms.

But, to the best of my knowledge, only one, very small, randomized controlled study of exercise for treating major depressive disorder in youth has ever been conducted. This study was nicknamed the DATE study (the Depression in Adolescence Treated with Exercise study by Hughes, Barnes, Barnes, DeFina, Nakonezny, & Emslie, and published in 2013 in a journal called, Mental Health and Physical Activity).

A brief review of the DATE study provides a glimpse into the potential of exercise as an intervention for treating depression in youth.

The DATE study randomized youth ages 12 – 18 years into an aerobic/cardio group (n = 16) vs. a stretching group (n =14). Although participants exercised independently and were given a variety of exercise alternatives (they could use Wii or Jazzercize, that’s right Jazzercize), both groups were involved in 12 weeks of rigorously monitored three times weekly exercise treatment protocols.

The results were statistically and clinically significant, with the aerobic condition showing remarkably fast responses and achieving a 100% response rate (86% complete depression remission). The stretching group improved more slowly, but also had a significant positive response (67% clinical response rate; 50% complete depression remission).

Now you might be thinking, that sounds pretty good, but how do those results compare with response rates from established medical treatments, like Prozac?

The authors shared that information. They reported that documented response rates in comparable fluoxetine (Prozac) studies with youth, showed, on average, about a 52% (Prozac) and 37% (placebo) response rate. Just to be clear, let’s put those results in order of which treatment looks best:

  1. Aerobic Exercise = 100% response rate
  2. Stretching = 67% response rate
  3. Prozac = 52% response rate
  4. Placebo – 37% response rate

But the authors didn’t stop there.

They noted that although Prozac shows beneficial treatment effects, clients who take Prozac and other antidepressants commonly experience uncomfortable side effects and occasional health-threatening adverse events. How do you suppose the exercise and stretch groups compared?

No big surprise here: They experienced ZERO side effects and ZERO adverse events.

In summary, the DATE study authors reported that, compared to antidepressant medication treatment with adolescents, exercise resulted in (a) a faster response rate, (b) a better response rate, (c) fewer relapses (n = 0) at six and 12 month follow-ups, and (d) zero side effects or adverse events (Hughes et al., 2103).

But here’s the kicker. Who exactly were these researchers?

This is my favorite part. The researchers were extremely high level and prestigious academics who primarily conduct pharmaceutical research. One of them was the guy responsible for the clinical studies that led to FDA approval of Prozac for treating youth with depression (Graham Emslie). The two biggest names on the study have repeatedly been funded by Eli Lilly, GlaxoSmithKline, Pfizer, and many more. The DATE study was funded by NIH.

Sadly, the DATE study hasn’t been replicated. I can’t find any new RCTs on exercise for  depression among adolescents. When I told this to Rita, she just quipped, “That’s probably because the authors were murdered by pharmaceutical companies in some back alley.”

I hope not. Because, to summarize, the DATE study supports the systematic use of exercise in youth with depressive symptoms OVER and INSTEAD OF antidepressants.

Who knew?

Just about everyone.