One more freebie in honor of suicide prevention month.
Building hope from the bottom up is one of the strengths-based suicide assessment and treatment techniques clinicians like best. I may be forgetting that I’ve already posted this here, but the approach is so popular that I’ll take that risk. Here’s the section for our Strengths-Based Suicide book . . .
Working from the Bottom Up to Build a Continuum of Hope
When clients are depressed and suicidal, they often think and talk about depressing thoughts and feelings. We shouldn’t expect otherwise. Even so, when clients ruminate on the negative, it fogs the window through which positive feelings and experiences are viewed. Within counseling, a potential conflict emerges: although clinicians want clients to problem-solve, focus on their strengths, and have hope for the future, clients are unable to generate solutions, can’t focus on their strengths or positive attributes, and seem unable to shake their hopelessness.
As discussed earlier in the case of Sophia, after an initial discussion of suicidality, there may come a natural time to pivot to the positive. One common strength-based tool for exploring what helps clients overcome their suicidality is a solution-focused question (Sommers-Flanagan, 2018a). If you’re working with a client who has made a previous attempt, you might ask something like “You’ve tried suicide before, but you’re here with me now, so there’s still a chance for a better life. What helped in the past?”
Although this is a perfectly reasonable question, the question may fall flat, and your client might respond with a hopelessness statement, “Nothing really ever helps.” This puts you in a predicament. Should you use Socratic questioning to identify a cognitive distortion? Should you interpret the distorted thinking in the here-and-now? Or should you retreat to empathy?
No matter what theoretical model you’re using, the predicament of how to deal with client non-responsiveness, negativity, or cognitive distortions remains. Let’s say you’re operating from a solution-focused or strength-based model and you ask the miracle question:
I’m going to ask you a strange question. What if, after we get done talking, you go back to doing your usual things at home, go to bed, and get some sleep. But in the middle of the night, a miracle happens, and your feelings of depression and suicide go away. You were asleep, and so you don’t know about the miracle. When you wake up, what will be the first thing you notice that will make you say to yourself, “Wow. Something amazing happened. I’m no longer depressed and suicidal.” (adapted from Berg & Dolan, 2001, p. 7).
Although the miracle question might do its magic and your client will respond with something positive, it’s equally possible that your client will say something like, “Not possible” or “The only way that would happen would be if I died in the night.” When clients are pervasively negative and hopeless, one error clinicians often make is to get into a yes-no questioning process that looks something like this:
Counselor: I’m sure there must be something that helps you feel more positive.
Client: I can’t think of anything.
Counselor: How about time with friends, does that help?
Client: No. I don’t have any real friends left.
Counselor: How about exercise?
Client: I can’t even get myself to exercise.
Counselor: Being in the outdoors helps with depression. Does that help?
Counselor: Have you tried medications?
Client: I hate medications. They made me feel like a zombie.
Entering into this exchange is unhelpful. In the end, both you and your client will be more depressed. Rather than continuing to ask what helps, try changing the focus to what doesn’t help. This shift is useful because when clients are experiencing suicidal depression, they’re more likely to resonate with negativity, and connecting with your client at the negative bottom is better than not connecting at all. The goal is to collaboratively build a continuum from the bottom up. By starting at the bottom, you’re simultaneously assessing hopelessness and intervening on the “Black-black” (as opposed to black-white) distorted thinking that you’re witnessing in session. Here’s an example:
Counselor: You’ve tried lots of different strategies to deal with your suicidal thoughts, without success. You’ve tried medications, exercise, and you’ve talked to your rabbi. Let’s list these and other things you’ve tried, and see which strategies were the worst. Of all the things you’ve tried, what was worst?
Client: I really hated exercising. It felt like I was being coerced to do something I’ve always hated. And it made me sore.
Counselor: Okay then. Exercise was the worst. You hated that. Of the other things you’ve tried, what was a little less bad than exercising?
Client: The medications. I just didn’t feel like myself.
Counselor: So that didn’t work either. So, of those three things, talking with your rabbi was the least bad?
Client: Yeah. It didn’t help much. But she was nice and supportive. I felt a little better, but I didn’t want to keep talking because she’s busy and I was a burden.
Focusing on the worst option resonates with a negative emotional state. For clients who are unhappy with the results of previous therapeutic efforts, beginning with the most worthless strategy of all is an easier therapeutic and assessment task, provides useful information, and is usually answered quickly. Subsequently, clinicians can move upward toward strategies that are “just a little less bad.” Building a unique continuum of what’s more and less helpful is the goal. Later, you can add new ideas that you or your client identify, and put them in their place on the continuum. If this approach works well, together with your client you will have generated several ideas (some new and some old) that are worth experimenting with in the future.
Beginning from the bottom puts a different spin on the problem-solving process. Even extremely depressed clients can acknowledge that every attempt to address their symptoms isn’t equally bad. Using a continuum is a useful tool for working with hopelessness and is consistent with the CBT technique, “Thinking in shades of grey.”