Yesterday I had a marvelous day with a group of about 35 wonderful mental health professionals and students in Ypsilante, Michigan. I was hosted by generous and kind faculty of Eastern Michigan University. I learned about the historical significance of “Ipsy,” along with anecdotes pertaining to the Ipsy water tower on post-cards, details of which—obviously because I’m so classy and sophisticated—I will not mention here.
The weather was marginally dreadful. We worried the in-person workshop would be cancelled and replaced with Zoom. Despite the weather, some people drove 90 minutes or more to arrive, which was just one small measure of their commitment to learning and their commitment to serving youth and families in counseling and psychotherapy. Whenever I’m in a room with professionals like the group yesterday, I have renewed hope in the world and in the future. The participants were: Just. Good. People.
As is my practice, I’m posting the ppts from the workshop here:
And here’s a PG-rated image of the Ypsilante water tower.
Toward the end of the workshop I engaged two participants in an activity that involved shaking imaginary soda pop bottles and opening them. One participant had brought her five-year-old daughter for the day (because of a school closure). As her mother and the woman next to her pretended to shake their imaginary bottles, and I was saying, “Shake, shake, shake,” the five-year-old, who had been incredibly well-behaved for the preceding 8 hours, began giggling in a way that couldn’t be described as representing anything other than pure joy.
In honor of my new five-year-old friend, I encourage you all to find time to giggle this weekend. Even better, find a child to giggle with; it will be time well-spent.
And here’s a photo of me having a giggle with a young person.
I’ve said it before and I’ll say it again: I have a friend who repeatedly espouses the glories of redundancy. Maybe that’s why some politicians stay on-message, regardless of the veracity of their statements. Of course, George Orwell and Hannah Arendt also commented on redundancy as persuasion, and not in a good way. I should emphasize that my goal for using redundancy and writing about the three-step emotional technique again has nothing to do with shaping your reality through political messaging.
When I presented on positive psychology to a bunch of UM STEM graduate students back in August, 2022, I made it very clear that I was not advocating toxic positivity. Nevertheless, in one of the student evaluations, someone complained that all I was doing was telling graduate students to “Cheer up.” Oh my. Sometimes people just hear what they want to hear. That’s a problem with over-valuing “lived experience.” When we over-value lived experience, then everything is viewed through our own, usually narrow and biased, personal lenses. Adler called this private logic. Too much private logic is too much private logic. Although we should strive to value, learn from, and share lived experiences, we should also have a shared value of this thing called . . . wait for it . . . science!
The next time I presented to the UM STEM grad students (in January, 2023), I made an explicit point of emphasizing my “non-toxic positivity street cred” by beginning the lecture with a short lesson on the three-step emotional change trick (which, BTW, with inspiration from Alfred Adler and Harold Mosak, we created as a youth psychotherapy technique in the mid-1990s). You can even find our (with Rita) original three-step article here: https://www.tandfonline.com/doi/abs/10.1300/J019v17n04_02 and a later book chapter here: https://psycnet.apa.org/record/2002-01308-098 and, of course, I’ve written about it on this blog, and have a youtube video demonstration: https://www.youtube.com/watch?v=ITWhMYANC5c, yada, yada, yada.
While presenting the 3SECT (which is what cool people call it) to the STEM students, there was a woman sitting toward the back. She had stationed her 8-year-old son still farther back, where he was sitting, head down, playing on her phone. I did the 3SECT thing, including the famous “And so I put my cat on my head” scene, emphasizing throughout, that the WHOLE reason for the 3SECT existing was because we should NEVER SAY CHEER UP to anyone, anytime!
The next day, I received the following email from the anonymous woman in the back (who generously gave me permission to share it here):
Hi John,
I was at your happiness seminar yesterday and was very disappointed I had to leave early. You may have noticed my son (who is 8) was sitting in the back playing a game on my phone during the seminar. I was delighted to find out this morning, while my 6-year-old daughter was having a meltdown trying to do her hair for school, that my son had been listening and absorbed your 3-step emotional change trick. He remembered the whole thing, and he asked his sister this morning if she wanted to learn it, but only if she wanted to change her own mood. He was clear that it wasn’t because he was trying to tell her to cheer up. He heard it all yesterday! Thought you might enjoy that little anecdote.
A few days later, she wrote:
We have gotten a lot of mileage out of your emotional change trick in the last few days.
I have to admit, I absolutely love it when people listen and get the message, but I truly and deeply love it EVEN MORE when 8-year-olds absorb messages while allegedly playing on a cell phone. I believe this may just be the scientific evidence (or is it my lived experience) I needed to validate that I am not and never have been a proponent of toxic positivity.
One other notable note. When searching (via Google) for my very own 3SECT video, I found that a counselor in Tennessee has copied one of my three-step blog posts and posted it as his own blog post. I was gobsmacked—with annoyance and flattery in equal proportions. If you want to read the blog post worthy of plagiarism (not the plagiarist’s version, which is the same, but my version that was so darn tempting that it literally caused plagiarism, here you go: https://johnsommersflanagan.com/2020/04/15/the-three-step-emotional-change-technique/
I’m ending now with a few core messages:
Don’t say “cheer up” to anyone.
Don’t get too over-focused on your own lived experiences, because, after all, everyone has their own lived experiences, and we should complement them all with scientific knowledge.
Don’t plagiarize.
If the person you plagiarized emails you, asking you to stop plagiarizing or provide a citation, don’t ignore that person.
And, whenever appropriate, follow in the anonymous 8-year-old’s footsteps and spread the good mood – without saying cheer-up!
In 1990, when I moved back to Missoula, Montana to join Philip and Marcy Bornstein in their private practice, my goal was to establish a practice focusing on health psychology. I believed deeply in the body-mind connection and wanted to work with clients/patients with hypertension, asthma, and other health-related conditions with significant behavioral and psychosocial components.
Turns out, maybe because I was the youngest psychologist in town, all I got were referrals from Youth Probation Services, Child Protective Services, local schools, and parents who asked if I could “fix” their children’s challenging behaviors.
I’d say that I made lemonade from lemons, but it turns out I LOVED working with the so-called “challenging youth.” There were no lemons! The work led to our Tough Kids, Cool Counseling book (1997 and 2007), along with many articles, book chapters, and demonstration counseling videos. Over the years I’ve had the honor of working extensively with parents, families, youth, and young adults.
In about 10 days, I’ll be in Ypsilanti, Michigan doing a full-day professional workshop on “Tough Kids, Cool Counseling.” If you’re concerned about the title, don’t worry, so am I. In the first few minutes of the day, I’ll explain why using the terminology “Tough Kids” is a bad idea for counselors, psychotherapists, and other humans.
Just in case you’re in the Eastern Michigan area, the details and links for the conference are below. I hope to see you there . . . and hope if you make the trip, you’ll be sure to say hello to me at a break or after the workshop.
When: Friday, March 10, 2023, 8:30 AM – 5:00 PM EST
Where: Eastern Michigan University Student Center, Second Floor – Ballroom B Ypsilanti, MI 48197
Counseling so-called “tough kids” can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many teenagers is, “Duh!” In this workshop, participants will sharpen their counseling skills by viewing and discussing video clips from actual counseling sessions, discussing key issues, and participating in live demonstrations. Attending this workshop will add tools to your counseling youth tool-box, and deepen your understanding of specific interventions. Over 20 cognitive, emotional, and constructive counseling techniques will be illustrated and demonstrated. Examples include acknowledging reality, informal assessment, the affect bridge, the three-step emotional change trick, asset flooding, empowered storytelling, and more. Four essential counseling principles, counselor counter-transference, and multicultural issues will be highlighted.
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
Engaging clients in a collaborative safety planning process is an evidence-based suicide intervention. The typical gold standard for safety planning is the Safety Planning Intervention (SPI) by Stanley and Brown (2012). You can access free material on the SPI and learn how to obtain professional training for using SPIs at this link: https://suicidesafetyplan.com/
As a part of the 7.5-hour Assessment and Intervention with Suicidal Clients video published by psychotherapy.net, I did a short (about 7 minute) demonstration of safety planning with a 15-year-old cisgender female client. The demo comes at the end of the session and naturally, I already know lots of information that can be integrated into the safety plan. Nevertheless, introducing and completing the safety plan is an excellent organizing experience.
In part, safety planning emerged as an alternative to what were called “No-suicide contracts.” No suicide contracts fell out of favor in the mid-to-late 1990s, because many clients/patients viewed them as coercive and liability-dodging behaviors by clinicians, and because they focused on what NOT TO DO, instead of what clients/patients should do, when feeling suicidal. Safety planning involves proactive planning for what clients can do to effectively cope during a suicidal crisis.
Victor Yalom of psychotherapy.net has given me permission to offer this video clip to everyone as a free resource to guide and inspire you as you work to develop your skills for collaborative safety planning. You can find a glittering array of videos, including the previously mentioned, three-part 7.5 hour classic at: https://www.psychotherapy.net/ and https://www.psychotherapy.net/video/suicidal-clients-series
Reframing, as a counseling and psychotherapy intervention, involves nudging clients toward viewing their thoughts, emotions, behaviors, and life situations from a different or new perspective. Reframing is an especially popular technique among cognitive, existential, and solution-focused therapists. In the following excerpt from our book on the strengths-based approach to suicide assessment and treatment, we discuss reframing . . . and what to do when it fails.
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Framing Pain and Suicidality as Evidence of a Normal Self-Care Impulse
Another reframe involves viewing suicidality as coming from a place of self-care or self-compassion. Using your own words, you might try a reframe like this:
As you talk about wanting to die, I’m struck that your wish for death also comes from your wish to feel better . . . and your wish to feel better is normal, natural, and healthy. What I’d like to do for now, is to partner with you on the healthy goal of feeling better. I need your help on this. For now, we can put your wish to die on the sidelines, and focus on feeling better. We can’t expect immediate positive results. Will you work with me to battle your pain, and little by little, to help you feel better?
This reframing message is intentionally repetitive, and almost hypnotic. The purpose is to engage with and activate the healthy part of the self that wants to feel better. When clients respond to this message, hope for positive outcomes may increase. If clients reject this reframing message, suicide risk may be high.
Framing Pain as Meaningful
Victor Frankl (1967) used reframing to address depressive symptoms in the following case.
An old doctor consulted me in Vienna because he could not get rid of a severe depression caused by the death of his wife. I asked him, “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?” Whereupon he said: “For her this would have been terrible; how she would have suffered!” I then added, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now you have to pay for it by surviving and mourning her.” The old man suddenly saw his plight in a new light, and reevaluated his suffering in the meaningful terms of a sacrifice for the sake of his wife. (1967, pp. 15–16)
Consistent with Frankl’s existential perspective, his reframe involves viewing suffering as meaningful. If clients view suffering as meaningful, life can feel more bearable.
When Reframes Fail
Reframing and redefining client emotional distress takes many forms. But, sometimes reframes don’t fit and don’t work. Reframes may be ineffective due to: (a) cultural insensitivity, (b) symptom severity, (c) inadequate rapport or alliance, and (d) countertransference (Lenes et al., 2020; Parrow et al., 2019). When your efforts to reframe fail, clients may withdraw or become agitated and you may risk a relationship rupture (Safran & Kraus, 2014). If the reframe doesn’t fit, process the issue (e.g., “Based on your reaction, it doesn’t seem like the idea I shared fits well for you”). After listening to your client’s response, you might need to proceed with strategies for rupture repair (see Sommers-Flanagan & Sommers-Flanagan, 2017). Relationship repair might include a direct apology and further processing. For example,
I’m sorry my idea for how to think about your pain wasn’t a good fit. But I’m glad you let me know it doesn’t fit. Lots of counseling is like an experiment. Sometimes we discover something doesn’t work. If you think something doesn’t fit or work for you, I will always want to know. Thank you for telling me.
When it comes to using reframing and redefinitions, your theoretical foundation is less important than the pragmatics of finding something that works for your client. The process involves: (a) identifying a potential reframe, (b) asking clients permission to try it out; (c) sharing the reframe; (d) observing client reactions, (e) verbally checking on client reactions and goodness of fit; (f) continuing to collaboratively experiment with the reframe or collaboratively discard it as a bad idea; and (g) addressing the relationship rupture—if one occurred.
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If you’re interested in our suicide book, give it a Google. Given the our unique hyphenated last name, it’s not hard to find.
In honor of National Suicide Prevention Month, I’m offering another chunk of information about suicide assessment and treatment. This information is an excerpt from our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach. In the book, we discuss assessment and treatment planning using a dimensional approach. The first (and central) dimension for suicide assessment and treatment is the emotional dimension.
When clients are depressed and suicidal, everyone—including family, friends, co-workers, counselors, and clients—wish for an improved emotional state. But often the process is slow, and as a result, the very people upon whom the client relies for support may lose patience. Supportive people, even counselors, may feel urges to say things that are emotionally dismissive, like, “Cheer up” or “Come on, you need to exercise!” or “Why can’t you do something to make your life better?”
Moving clients out of despair and into the light is difficult; if it were otherwise, clients would resolve suicidality on their own. Directly or indirectly suggesting to clients in suicidal pain to “cheer up” often backfires, creating anger, hostility, and resistance to treatment; this resistance is a powerful phenomenon called, psychological reactance(Brehm & Brehm, 1981).
Psychological reactance occurs when clients perceive their ultimate freedoms as threatened. If clients sense that clinicians want to coerce them to stay alive, in response, they may dig in their heels and engage in behaviors designed to restore feelings of autonomy. Psychological reactance is one explanation for why clients who are suicidal sometimes vehemently resist help, insisting on their right to think about and act on suicidal impulses. Repeated empathic acceptance of the client’s emotional pain is one way to avoid activating reactance; empathic acceptance also allows clients to begin exploring and addressing key emotional issues in counseling.
Key Emotional Issues to Address
Many emotional issues are relevant to suicide treatment planning. These include: (a) excruciating distress, (b) specific disturbing emotions, such as, acute or chronic shame and guilt, anger, or sadness, and (c) emotional dysregulation. In this next section, we briefly review core emotional issues that you may guide your treatment planning. Later in the chapter we provide case examples and vignettes illustrating methods for working in the emotional dimension.
Excruciating Distress
Shneidman referred to the emotional state surrounding suicide as “psychache” or unbearable distress. He wrote: “The suicidal drama is almost always driven by psychological pain, the pain of negative emotions—what I call psychache. Psychache is at the dark heart of suicide; no psychache, no suicide.” (2001, p. 200, italics added).
Even when using a strength-based or wellness model, exploring the “pain of negative emotions” or excruciating distress is usually your first focus. Sometimes, to avoid activating reactance or resistance, you’ll need to stay with your client’s emotional pain longer than you’d prefer. Staying with your clients’ pain not only helps bypass resistance, it also models that facing negative affective states without fear, avoidance, or dissociation requires personal strength. Even so, as you focus on suicidal pain, you might wish the client would immediately adopt a more positive mindset, or find the process difficult to bear. You also might need to turn to colleagues or your self-care plan for support. Nevertheless, job one in the emotional dimension is to recognize and resonate with your client’s emotional pain.
Acute or Chronic Shame and Guilt
Shame and guilt are non-primary emotions because they involve significant self-reflection. Shame connotes beliefs of being unworthy, defective, or bad. Shame is often directly linked to core beliefs about the self, and activated by particular life situations. In contrast, guilt is more specific, often associated with certain actions or lack of actions (e.g., “I should be doing more to fight racism” or “I shouldn’t have been so critical of my professor”). Generally, guilt can lead to shame, and shame is more likely to ignite suicidality. Reducing or resolving shame or guilt may be a crucial therapeutic goal.
Suicidal thoughts are often accompanied by shame. Cultures around the world have historically judged death by suicide as a shameful or sinful event, and many still do. Your client’s experience may be something like, “Not only do I have suicidal thoughts—which are terrible in their own right—but the fact that these thoughts exist in my mind also make me a bad person.” This double dose of negative judgment, emotional pain plus self-condemnation, often needs to be addressed in counseling. One strategy that may fit into your treatment plan is to help clients develop greater self-compassion as a method for countering their self-condemnation.
Anger
In graduate school, we had a professor who suggested we consider this question: “Who is this client planning to commit suicide at?” Often, people who are suicidal carry great anger toward one or more friends, lovers, or family members and thus think of suicide as an act of revenge. Counselors should listen for underlying themes that involve using suicide as a behavioral goal for getting even or intentionally hurting others (Marvasti & Wank, 2013).
Thoughts of dying by suicide sometimes emerge as a revenge fantasy. Thoughts like, “I’ll show them” or “they’ll suffer forever” represent anger, along with the desire to punish others. It can be tempting to point out to clients that death is an irrationally high price for fulfilling revenge fantasies. However, helping clients express, accept, and understand the depth of their anger will usually reduce suicidality more efficiently than pointing out that death is a maladaptive revenge strategy. If revenge is central and forgiveness isn’t a viable option, then an apt philosophy to gently infuse into your clients is that the best revenge is a well-lived life.
Sadness
Major depression is the psychiatric diagnosis most commonly linked with suicide attempts, especially among older adults (Melhem et al., 2019). Clients who present with sadness as a dominant emotion may or may not meet diagnostic criteria for major depression. However, when sadness and the associated emotions and cognitions of irritability, regret, discouragement, and disappointment are central sources of distress, we recommend targeting those symptoms with evidence-based counseling interventions. Weaving positive psychology or happiness interventions into treatment planning is especially appropriate for clients struggling with sadness and depression (Seligman, 2018; Rashid & Seligman, 2018). More information about evidence-based approaches and positive psychology interventions is provided later in this chapter and in upcoming chapters.
Emotional Dysregulation
Clients who are suicidal may exhibit emotional dysregulation during counseling sessions and in their everyday lives. Clients may be emotionally labile, shifting from expressing anger to feelings of affection, appreciation, and deep connection. Clients may share stories of repeated maladaptive emotional overreactions to life’s challenges. Although unstable relationships, emotional swings, and explosive anger fit with the diagnostic criteria for borderline personality disorder, when clients are experiencing excruciating distress, they may behave in ways that resemble borderline personality disorder. However, instead of pathologizing clients with a personality disorder diagnosis, we recommend framing client behaviors using a social constructionist strength-based orientation, such as: Given enough situationally-based stress, including, as Linehan (1993) noted—emotionally invalidating environments—nearly everyone becomes dysregulated and appears unstable. Normalizing dysregulation as a natural response to intense distress helps maintain a strength-based perspective.
Treatment plans for clients who are suicidal often include teaching emotional regulation skills; this translates to helping clients become more capable of regulating themselves in the face of emotionally activating circumstances. Linehan’s (1993, 2015) protocols for working with clients with borderline personality characteristics are recommended for emotional regulation skill development. However, alternative approaches exist, some of which come from positive psychology, happiness, and well-being literature (Hays, 2014; Lyubomirsky, 2007, 2013; see Wellness Practice 4.1).
Rita has slipped away with a friend to go to a Tippet Rise (https://tippetrise.org/events/36201) concert. IMHO, Tippet Rise has amazing concerts. As a means to cope with my jealousy, I’ve decided to pass along a couple of freebies I found in my email inbox. Given that most of the freebies I receive in my inbox are related to someone who wants to trick me into becoming a few hundred million bucks richer, rest assured, I’ve screened out the fake-freebies, and have vetted these.
First, from Dr, Thomas McMahon of Yale University. He wrote about a free eBook:
Youth Suicide Prevention and Intervention offers a comprehensive review of current research on the public health crisis and best practices to prevent youth suicide. The volume was edited by John P. Ackerman, PhD from the Center for Suicide Prevention and Research at Nationwide Children’s Hospital and Lisa M. Horowitz, PhD, MPH from the National Institute of Mental Health. It includes 18 chapters organized into five sections on (a) foundations for suicide prevention, (b) prevention and postvention in school settings, (c) screening and intervention with suicidal teens, (d) prevention and intervention for special populations, and (e) the development of more effective systems of prevention.
With support provided by Nationwide Children’s Hospital Foundation and Big Lots Behavioral Health Services, the volume is available in an open access format. An electronic copy of specific chapters or the entire volume can be downloaded free of charge here.
Second, Amanda DiLorenzo-Garcia, Ph.D, of the University of Central Florida shared info about a free virtual symposium. Here’s what she wrote:
In honor of suicide prevention month, the Alachua County Crisis Center hosts a free mental health symposium. It is an incredible resource for counseling students, counselors, parents/guardians, teachers, first responders, etc. Therefore, it is open to the community at large.
This year the symposium is titled Holding Space Together: Addressing the Mental Health Needs of 2022. Topics vary and include suicide prevention, parenting, mindfulness, black mental health, burnout, tapping skills, ADHD, etc. The sessions will take place September 12-15th, 2022 between 5:30-8:30pm EST virtually. Sessions are facilitated by Alachua County Crisis Center staff, community agency mental health providers, and Counselor Education faculty from various institutions. The information is geared toward the general community; however, there are sessions that counselors and counseling students may benefit from attending as well.
That’s all for now. The book section is below. Have a great holiday weekend . . .
John S-F
Working in the Behavioral Dimension
When times are difficult and life feels intolerable, many people think about suicide as an alternative to life. But most individuals, despite intense emotional and psychological pain, don’t act on their suicidal thoughts. In fact, people often cling to life even in the face of great pain. Philosophers, suicidologists, and evolutionary biologists all point to the likelihood that humans are genetically predisposed toward survival (Glasser, 1998).
For a variety of biological, psychological, and environmental reasons, it’s usually easier to get people to experiment with new behaviors than it is to get them to stop engaging in their old, habitual behaviors. As children, you may have been repeatedly told “don’t smoke, don’t drink, don’t date that person, and don’t you dare miss your curfew again.” But often, those admonitions didn’t stick. Given how difficult it is to successfully get people to comply with prohibitions makes the “don’t act on suicide impulses” goal of this chapter an arduous task.
This chapter isn’t so much about telling people what not to do, as it is on helping them identify and act on alternative behaviors. Our aim is to stay primarily strength-based, helping clients flood their personal lives with positive behaviors. We’ll review and describe methods for building healthy behavior patterns, developing positive safety plans, and more.
Key Behavioral Issues to Address
The empirical research is thin, but several near-term predictors of suicidal behavior have been identified. These include: (a) active suicide planning or intent, (b) dispositional pain insensitivity and acquired suicide capability, (c) impulsivity, and (d) access to lethal means (Joiner, 2005; Klonsky & May, 2015; O’Connor, 2011).
Suicide Planning or Intent
Suicide ideation is common—especially among clients and students who are experiencing depressive symptom. But early everyone who thinks about suicide, chooses not to act on their thoughts.
Suicide planning is a step closer to action. When clients have suicide plans, their ideas have taken shape into potential behaviors. Typically, clients who have plans that include greater specificity, higher lethality, more accessibility, and less chance of being prevented are at higher risk. Nevertheless, most clients who have suicide plans don’t act on them.
Suicide intent—although still in the realm of thought—implies enactment of a plan. Suicide intent is especially disturbing when associated with repeated suicide attempts or rehearsal of specific suicide methods. Mentally rehearsing or physically practicing suicide behaviors makes the manifestation of those behaviors more likely. However, when intent is high, planning and rehearsing may not be required; given an opportunity, clients with extremely high intent may spontaneously and impulsively jump from moving cars, dash into heavy traffic, throw themselves into bodies of water, or find whatever means they can to end their lives.
Clients with high suicide intent sometimes require hospitalization and may need to be on safety watch. Pulling clients back from the suicidal edge and modifying their intent is frightening, but potentially gratifying. If you work with clients who have extremely high intent, remember to focus on your own safety and find support for potential vicarious traumatization.
Suicide Desensitization or Acquired Capability
Some individuals are unusually fearless and sensation-seeking from birth. O’Connor (2011) refers to this as dispositional pain insensitivity. In contrast, other individuals, born with normal pain sensitivity and a normal aversion to death can, over time, achieve what Joiner (2005) called acquired capability; this process is also called suicide desensitization. Joiner wrote: “The capability to act on (suicidal) desire is acquired over time through exposure to painful and provocative events” (2005, p. 3).
The predisposition to fearlessness and high pain tolerance likely has biogenetic roots (Klonsky & May, 2015). In such cases, psychosocial therapeutic strategies are limited. Identifying high-risk and high-vulnerability situations and activities and then working collaboratively with clients on appropriate coping strategies may be the best treatment option.
Clients who have acquired capability have become desensitized to suicide over time (Joiner, 2005). Desensitization can be unintentional or intentional. Repeated trauma or exposure to chronic physical pain can produce desensitization. Alternatively, self-mutilation and substance abuse and dependence are intentional behaviors that produce numbness and can reduce fear of pain and suicide.
Impulsivity
Clients who are highly impulsive tend to act suddenly, without planning, and without reflective contemplation. Impulsivity can be examined as a trait—individuals who display a pattern of acting without planning and do so across time and different circumstances have trait impulsivity. Impulsivity can also be situationally triggered; ingesting alcohol, being around certain people, or being in particular situations can magnify impulsivity.
Clients diagnosed with bipolar disorder, borderline personality disorder, and substance use disorders are more inclined toward impulsive behavior patterns and suicide. Effective treatments of impulsivity are limited. Some possibilities include (a) dialectical behavior therapy (Linehan, 1993), (b) lithium (Cipriani et al., 2013), and (c) individual or group treatment for substance abuse (López-Goñi et al., 2018).
Access to Lethal Means
Easy availability of lethal means increases suicide risk. Firearms are far and away the most lethal suicide method. Although firearms can quickly become a politicized issue, access to firearms unarguably magnifies suicide risk (Anestis & Houtsma, 2018). Other common and lethal suicide methods include poisoning (using pills or carbon monoxide) and suffocation/asphyxiation. Reducing access to lethal means or enhancing firearms safety are common strategies that reduce immediate suicide potential.
A quick review of recent informed consent research leads me to think that informed consent should be a perfect blend of evidence-based information about the benefits, risks, and process of psychotherapy. Like all good hypnotic inductions, informed consent, has the potential to stir positive expectations or activate fear. But when I look at all that we’re supposed to include in informed consents I wonder, does anyone really read them? Informed consent could have significant effects on treatment process and outcome. But only if clients actually read the written document.
The alternative or a complementary strategy is a good oral description of informed consent. Again, as someone trained in hypnosis and sensitive to positive placebo effects, I’m inclined to use informed consent to set positive expectations. I think that’s appropriate, but it’s also easy for us, as practitioners, to become too enthusiastic and unrealistic about what we have to offer. The truth is that no matter how much passion I may have for a particular intervention, if there’s absolutely no scientific evidence to support my niche passion, and there is evidence to support other approaches, then I could come across like someone promoting ivermectin for treating COVID-19. If you think about the people who promote ivermectin, it’s likely they’re either (a) uninformed/misinformed and/or (b) profit-driven. To the extent that all professional helpers or healers aim to be honest and ethical in our informed consent processes, we should strive to NOT be uninformed/misinformed and to NOT be too profit-driven. I say “too profit-driven” because obviously, most clinical practitioners would like to make a profit. All this information about being balanced in our informed consent highlights how much we need to read and understand scientific research related to our practice and how much we need to check our enthusiasm for particular approaches, while remaining realistic, despite potential financial incentives.
Informed Consent: Who Reads Them? Who Listens?
If informed consents are difficult to read and comprehend, they may be completely irrelevant. On the other hand, in their obtuseness, they may function like the confusion technique in hypnosis and psychotherapy. Although the confusion technique is pretty amazing and I’ll probably write more about it at some point, it’s inappropriate and unethical to use the confusion technique in the context of informed consent.
In medical and some therapy settings, informed consent often feels sterile. If you’re like me, you quickly sign the HIPAA and informed consent forms, without taking much time to read and digest their contents. The process becomes perfunctory.
I recall a particularly memorable pre-surgery informed consent experience. After hearing a couple of low probability frightening outcomes and experiencing the sense of nausea welling up in my stomach, I stopped listening. I even recall saying to myself, “I can choose to not listen to this.” It was an act of intentional dissociation. I knew I needed the surgery; hearing the gory details of possible bad outcomes only increased my anxiety. Here’s a journal article quote supporting my decision to stop listening, “Risk warnings might cause negative expectations and subsequent nocebo effects (i.e., negative expectations cause negative outcomes) in participants” (Stirling et al., 2022, no page number)
Informed consent flies under the radar when clients or patients stop listening. Informed consent also flies under the radar because many people don’t bother reading them. In our theories textbook we have nice examples of how therapists can write a welcoming and fantastic informed consent that cordially invites clients to counseling. Do these informed consents get read? Maybe. Sometimes.
Informed consent has the potential to be powerful. To fulfill this potential, we need to contemplate on big (and long) question: “How can we best and most efficiently inform prospective clients about psychotherapy and maintain a balanced, conversational style that will maximize client absorption of what we’re saying, while appropriately speaking to the positive potential of our treatment and articulate possible risks without activating client fears or negative expectations?”
Here’s an abbreviated guide: Provide essential information. Use common language. Be balanced.
For example:
“Most people who come to counseling have positive responses and after counseling, they’re glad came. A small number of people who come to counseling have negative experiences. If you begin to have negative experiences, we should talk directly about those. Sometimes in life, confronting old patterns and talking about emotionally painful memories will make you feel bad, sad, or worse, but these negative feelings should be temporary. Getting through negative or difficult emotions can open us up to positive emotions. My main message to you is this: No matter what you’re experiencing in counseling, it’s good and important for you to share your thoughts, feelings, and reactions with me so we can make the adjustments needed to maximize your benefits and minimize your pain.”
I could go on and on about informed consent, but that might reveal too much of my nerdiness. These are my reflections for today. Tomorrow may be different. I just thought I should inform you in advance that consistency may not be my forte.
Emily Sallee and I had an excellent (and inspiring) day 1 at the 2022 MASP Summer Institute. The MASP members and other participants have been fabulous. Today, we built a foundation upon which we will build great things tomorrow.
What’s up for tomorrow? Advanced treatment planning using the seven-dimensional strengths-based model. Just in case you’re at the Summer Institute OR you want a peek into what we’re doing, here are some handouts.
John Sommers-Flanagan 