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.
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.
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.
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.
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.
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.
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.
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 . . .
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.
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.
“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.
As a part of my presentations for ACA last week, I prepared a couple of short video clips. These clips are part of a much, much longer, three-volume (7.5 hour) video series produced and published by psychotherapy.net. Victor Yalom of psychotherapy.net gave me permission to occasionally share a few short clips like these. If you’re interested in purchasing the whole video series (or having your library do so), you can check out the series here: https://www.psychotherapy.net/videos/expert/john-sommers-flanagan
IMHO, although the whole video series is excellent and obviously I recommend it, these clips can be used all by themselves to stimulate class discussions. Check them out if you’re interested.
Kennedy is a 15-year-old cisgender female referred by her parents for suicidal ideation. Although a case could be made for using a family systems approach, this opening is of me working 1-1 with Kennedy. When I show this video, I like to emphasize that I’m using a “Strengths-based Approach” AND I’m also asking a series of questions that pull for Kennedy to talk about her distress. This is because clients generally need to talk about their distress before they can focus on strengths or solutions. Instead of practicing “toxic positivity” this approach emphasizes the need to come alongside and be empathic with client pain and distress.
Chase is a 35-year-old cisgender Gay male. In this brief excerpt, I try (somewhat poorly) to use a pattern interpretation to facilitate insight into his history of social relationships. Chase’s response is to dismiss my interpretation. Back in my psychoanalytic days, we talked about and used trial interpretations to gauge whether an abstract-oriented psychodynamic approach was a good fit for clients. Chase’s response is so dismissive that I immediately shift to using a very concrete approach to analyzing his social universe. Then, when Chase isn’t able to identify anyone who is validating, I use a strategy I call “Building hope from the bottom up” to help him start the brainstorming process.
A big thanks to psychotherapy.net and Victor Yalom for their support of this work.
As always, if you have thoughts or feedback on these clips or life in general, please feel free to share.
As I type, Steven Hayes, the creator of acceptance and commitment therapy (ACT), is talking in a variety of voices about mindful acceptance. Earlier, he mentioned something about the whole human genome. In case you don’t already know, Steve is an older white guy. His writing about psychotherapy is fantastic. I really like his Ted talk. I’ve found his question, “What shall we do with our difficult thoughts?” an excellent prompt to reflect on.
Steve and I have a history. I’m glad to say that I’ve mindfully accepted that he missed his supervision appointment with me at AABT (now ABCT) back in 1987 in Los Angeles. Really. I’ve let go Steve standing me up, not because I’m all that good at forgiveness, but because him skipping out on our chance to meet makes for a better story. In fact, in this mindful moment, I’ve accepted him missing our meeting so completely that I have no urge to try to meet him today.
This is my first Networker “Symposium.” I hadn’t realized it was quite the distinctive thing. They’ve got numbers you can put on your badges to represent how many times you’ve attended the Symposium. Although it’s just a conference, it does have a particular flair and feel. From the beginning, there was movement, talk about love and sex-tech, dancing, singing, and learning. The breadth of content and diversity of attendees has been marvelous.
I started the first day with a workshop on Love and the Therapeutic relationship with Sabrina N’Diaye. Later, I took in a workshop on Tech-Sex with Tammy Nelson, author of Getting the Sex you Want. Nelson basically blew my mind. Did you know there are “devices” you can use to remotely vibrate your romantic partner’s genitalia? I didn’t . . . and maybe I didn’t want to. Did you know someone commented in the session that “Dominants” use that vibrating device to issue “commands?” I was sitting next to a professional cuddler and sexual surrogate. She was delightful. Steve Hayes (and Ram Dass) would be proud of the fact that I managed my difficult thoughts by staying in the here and now instead of trying to imagine her work or think about what the dominatrix had shared. Just saying. My mind remained as pure as the water of the Stillwater River.
There’s been lots of talk about racism at the Symposium. That’s a good thing. I’m better for it. The more we can all be less racist or anti-racist and aware of our biases, the better. Of course, while I’m typing this, my almost erstwhile buddy Steve continues to talk (and sometimes mumble). I’m aware (somewhat painfully) that I’m more “like” him in age and gender and ethnicity and can’t help but lament that (sorry Steve). Being an old white guy brings privilege (or advantage, as our first keynote speaker preferred). At the same time, looking in the mirror and seeing myself as just another old white guy also brings along gut-level unpleasantness.
Yesterday’s highlights were listening to Ester Perel (very smart, very articulate, very impressive) and learning more about Susan Johnson and her personal history of growing up in a Pub. We also listened to three young women talk about the couple therapy experiences that changed them. Fabulous.
One of my (many) take-aways from the past two days is for me to NOT be THAT old WHITE guy. I want to be a different white guy. How does that work? Among other things, I will try not to think too much of myself . . . or mumble.
Steve is now trying to get us all to love ourselves. That’s a nice idea. Someday, Steve, I hope to get there. But, to channel our Saturday morning Symposium keynote speaker, Emily Nagoski, most of the time, things just don’t fucking work.
Wait. I know that sounds negative. Among many of her excellent points about coping with burnout, Emily played a cool song (of her twin sister’s), a song liberally infused with the F-word. If you’ve ever experienced technology frustration (which I suppose even happens with sex-tech), you should listen. Here’s the link: https://www.youtube.com/watch?v=eottd9Lw8l4 If you listen, don’t think about sex-tech at the same time. There’s no need to thank me for this great advice.
I’ve now abandoned Steve, in favor of one of the darling presenters of the Symposium and PESI. Sorry Steve . . . but I know you’ll mindfully accept your experience of me abandoning you. . . partly because you’ve never acknowledged my existence anyway (see, I’m totally over that 1987 incident).
There’s a woman talking . . . softly . . . without the changing voice routines of Steve Hayes. As she drones on, she mentions that therapy and therapists can be triggering. . . which is interesting given that I can’t find any affect in her voice. I’ve taken a seat on the floor in the back corner of the room and quickly recognized she’s right. She’s right because she instantly triggered me as I walked in the door with her monotone statement that talk therapy doesn’t work for trauma (what about CPT . . . or?). She continued to trigger me with her statement that PTSD was only identified in the 1970s (what about the diagnosis of war neurosis or battle fatigue or the many other earlier versions of PTSD?). And she finished triggering me with her laudatory comments on narrative therapy (does she NOT think of narrative therapy as “talk therapy?”).
I know my job here. Mindful acceptance. Learn what I can. Maybe the learning is about my own triggers or my own internal lament over being an increasingly irrelevant old white guy. Maybe the learning is about how to stay calm and embrace both ends of the constant dialectics and polarities of life.
On the whole, I’m so glad to be here at the Symposium, with Rita, and so grateful to continue learning. The fact that the conference has stimulated some of what Steve would call “difficult thoughts” is a blessing to be mindfully accepted. How else do we learn? How else do we grow? Should we expect to be constantly confronted with easy, comfortable, and affirming thoughts?
I think not. And I accept that . . . in my whole human genome.
Jon Sperry asked if I could write the foreword for a book he and his dad wrote with Oxford University Press.
Because the truth will set me free, I should admit, I’d never written a foreword before. More truth . . . I went ahead and said “Yes” to Jon because (a) I was honored and didn’t want the opportunity to write my first foreword slip away, (b) the book was (is) cool (it’s “The 15-Minute Case Conceptualization”), and (c) Jon Sperry is one of the nicest guys on the planet.
And for even more information about this excellent book, my first-ever foreword is below.
I’ve needed this book for 30 years.
Just last month (before reading this book), I was standing in front of a Zoom camera, trying to teach the basics of case conceptualization to a group of 23 master’s and doctoral students. All of my fine-grained case conceptualization wisdom was being channeled into a single visual and verbal performance.
“My left hand,” I said, “is the client’s problem.” Pausing briefly for dramatic effect, I then continued, “and my right hand is the client’s goal.”
My new-found nonverbal gestures are mostly a function of seeing myself onscreen, and therefore wanting to avoid seeing myself (and being seen by the class) as boring. To add spice to my case conceptualization gesturing. “Case conceptualization is simple,” I said. “All it is, is the path we take to help clients move from their problem state . . . toward their goal state (I finished with a flourish, by wiggling the fingers on my raised right hand).”
But boiled down truths are always partly lies. Despite my fabulous mix of the verbal and nonverbal, I was lying to my students. At the time, I had thought of it as a little white lie, all for the higher purpose of simplification. And although I still like what I said and still believe in the rough truth of my visual case conceptualization description, after reading Len and Jon Sperry’s illuminating work on case conceptualization, I better understand what I should have said.
Case conceptualization is not simple. As the Sperry’s describe in this book, case conceptualization—even when summarized well—includes multiple dimensions of human behavior along with clinician perception, judgment, and decision-making. I needed much more than a few wiggly fingers to communicate the detailed nuances of case conceptualization.
What these authors have done in this book is the gracious service that great writers do so well: They have done our homework for us. They’ve read extensively, taken notes, and gifted us with elegant summaries of dense and complex concepts. They’ve made it easy for us to understand and apply the principles and practices of case conceptualization.
What I might like best is how they transformed a bulky and inconsistent literature into simple, therapist-friendly principles. They emphasize the explanatory, tailoring, and predictive powers of case conceptualization. I’ve never organized case conceptualizations using those “powers” but doing so was like switching on a light-bulb. Of course, case conceptualizations should explain the relationships between client problems and client goals and shine a bright light along the path, but rarely do theorists or writers make this linkage so efficiently. Their second principle, “tailoring” case conceptualizations to individual and diverse clients, is an essential, idiographic, Adlerian idea. The whole idea of tailoring counters the all-too-frequent cook-book approach to case conceptualization. Tailoring breathes life into creating client-specific case conceptualizations. And of course, case conceptualizations need predictive power; Len and Jon equip us with enough foundational predictive language to improve how we evaluate our own work.
Many other examples of how elegantly the authors have done our homework are sprinkled throughout this book. Here’s another of my favorite examples.
In chapter 2, they take us (in a few succinct paragraphs) from what Theodore Millon described as eight evolutionarily-driven personality disorders to eight crisply described behavioral patterns. What I love about this is that Len and Jon’s wisdom transforms what might otherwise be viewed as a pathologizing personality disorder system into language that can be used collaboratively with clients to identify contextually maladaptive interpersonal patterns. This is a beautiful transformation because it spins psychopathology into something clients not only understand but will feel compelled to embrace. The process goes something like this:
Therapist and client engage in an assessment process that touches on the client’s repeating maladaptive behavior patterns. These behavior patterns are palpably troubling and far less than optimal for the client.
As all clinicians inherently know, touching upon clients’ repetitive maladaptive behavior patterns can activate client vulnerability. This is a primary challenge of all counseling and psychotherapy: How can we nudge clients toward awareness without simultaneously activating resistance? For decades, psychoanalysts managed this through cautious trial interpretations. Solution-focused therapists dealt with this by never speaking of problems. Gently coaxing ambivalent clients toward awareness and change is the whole point of motivational interviewing.
When addressed in a sensitive and non-pathologizing way, deep maladaptive behavior patterns can be discussed without activating resistance or excessive emotionality. This is a critical and not often discussed part of case conceptualization. Len and Jon illuminate a path for gentle, sensitive, and collaborative case conceptualization.
When clients can feel, recognize, and embrace their maladaptive behavioral patterns in the context of an accepting therapeutic relationship, insight is possible. In the tradition of Adlerian therapy, when insight happens, client interest is piqued and motivation to change spikes. Good case conceptualizations articulate problem patterns in ways that compel clients to invest in change.
I’m not surprised that Len and Jon Sperry have produced such a magnificently helpful book. If you dig into their backgrounds and conduct a case conceptualization of their personality patterns, you’ll discover they wholeheartedly embrace Alfred Adler’s work and consequently, much of what they do is all about social interest or Gemeinschaftsgefühl. Len and Jon Sperry are in the business of helping others. Reading their book has already helped me become better at teaching case conceptualization. I appreciate their work, and, no doubt, the next time I begin waving my hands in front of my Zoom camera, my students will appreciate their work too.
Last year, for the first time, we offered the Art & Science of Happiness simultaneously as a 3 credit COUN 195 course through the University of Montana and as a non-credit course open to community members through UMOnline. The course was fully online. Many students took the course “live” and synchronously; others enrolled and completed the course at their convenience.
We had 50 students sign up for the course: 30 UM students took the course for credit; 20 were “community” members (hailing from Missoula, Browning, Billings, Pennsylvania, and Canada). Many of the UM students were 19 to 22 years-old. Many of the community members were 60 to 87 years-old. The inter-generational synergy was fabulous.
What You Get in the Art & Science of Happiness
25+ instructional hours with John Sommers-Flanagan, and occasionally Rita Sommers-Flanagan. You can experience these lectures synchronously through Zoom, or asynchronously at times that work into your personal schedule.
10+ hours of small group counseling designed to facilitate reflection, discussion, and experiencing of evidence-based happiness activities (these “lab” groups can be face-to-face or via Zoom)
8 hours of individual supportive wellness counseling with a Master’s student from the Counseling Department at the University of Montana (these services are face-to-face or via Zoom and on a first-come, first served basis, because we have a limited number of available counselors-in-training)
The cost for community UMOnline participants is $250. If that sounds expensive, think of it this way. You get 40+ total hours of a combination of large group instruction, small group counseling, and individual counseling, which translates to $6.25 an hour.
Research from the two previous semesters indicate that some (not all) participants experience:
Reduced depression symptoms (in some cases, depressive symptoms were substantially reduced)
Increased hope and optimism
An increased rate of positive emotions
A reduction in headaches
Greater feelings of social connection
Comments from Previous Community Participants
“Words are inadequate to express my gratitude for the Happiness Class and your amazing expertise. Literally transforming my life after a very difficult and sad nine months; plus, it’s a heckuva lot of fun. Again, thank you.”
“I found the course interesting and rewarding far beyond my expectations.”
“I feel a major shift in my thinking. I am now more focused on gratitude and living in the moment and have developed an unexpected confidence about facing the inevitable challenges that lie ahead, a confidence that even others have noticed.”
[In response to the group counseling component] “I appreciate the interactions that I have with everyone in my group. We are all very different, yet willing to be open and share our thoughts. I wasn’t sure what this would be like and I am already liking it a lot.”
[In response to a homework assignment] “I am applying a very simple formula to myself…When I become aware of how grumpy and scared and negative I feel about an issue in our family, I consciously think of two things for which I feel grateful. It fills the basket of my emotions with more positivity and opens up a new way of approaching my worries.”
The course is offered “live” on Tuesdays/Thursdays from 1pm to 2:20pm, beginning on January 18, 2022, ending the week of May 9, 2022. However, because the course is fully online via Zoom, you can also take the course asynchronously.
I believe this course content is very helpful, and so I’d like to make this course available as widely as possible. Please help me by sharing this information with others. Also, because I’m paid by the University of Montana to teach this course, all proceeds are returned to the University of Montana in general, and the Department of Counseling, in particular.
The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.