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’13 Reasons Why’: Strengths, challenges and recommendations

By Laura Shannonhouse, Julia L. Whisenhunt, Dennis Lin and Michael Porter September 4, 2017

The Netflix series 13 Reasons Why has launched a national discussion regarding teen suicide, motivating a webinar response from professional organizations about how to shape the dialogue, dozens of editorials and millions of cautionary letters home from schools to parents across the country.

The series, based on a novel, is narrated by high school student Hannah Baker, who made a series of cassette tapes to be passed to 13 individuals she argues contributed to her reasons for dying. Her story is seen through the eyes of a peer, Clay, who listens to the tapes. He comes to understand Hannah’s perspectives about those people and events she claims motivated her suicide, which include Clay’s own (in)actions.

The series has been critically acclaimed for the acting and commended for addressing challenging topics, such as bullying/cyberbullying, sexual assault and teen suicide. However, school administrations, school counseling associations, suicide prevention organizations and counseling/psychology associations such as the American Foundation for Suicide Prevention (AFSP), the Suicide Prevention Resource Center (SPRC), the American School Counselor Association (ASCA) and the National Association of School Psychologists (NASP) have advised caution because of the graphic nature, revenge fantasies and potential contagion effect. This article highlights strengths and major challenges of the series. It also provides recommendations that have been underrepresented, though not absent, in the discussion.



1) Raising awareness that suicide is a real problem.

According to the Centers for Disease Control and Prevention (CDC), suicide is a major public health issue. The most recent  statistics available note that among high school students, 17 percent have seriously considered suicide, while 8 percent have attempted suicide within the past 12 months. We know that for every suicide, there are many survivors, including the family and friends of the person and those who have experienced psychological, physical and social distress after exposure to a suicide.” The most commonly cited statistic is that each suicide directly affects six people; however, more recent research argues there are between 45 and 80 survivors per suicide.

In 2015, there were more than 44,000 reported suicide deaths, including 5,191 deaths by suicide among those ages 15 to 24. However, this statistic includes only those that were reported. Although there is no consensus on the rate of under-reporting due to stigma or ambiguous cause of death, the best analysis suggests that for each completed youth suicide, there are 100-200 times as many nonfatal suicide actions.

Combining CDC data with our current understanding of rates of suicidal ideation in youth, in this moment there are close to 15 million people in the U.S. who think of suicide in any given year. Suicide is a very real public health issue; when it is ignored, stigmatized or minimized, we as a community are missing the chance to prevent it.

2) Even professional counselors may not be ready to respond to a suicidal situation.

Because counselors often receive referrals of clients who are suicidal, counselors’ competency in identifying and intervening with those at risk is crucially important. However, the overtaxed counselor in 13 Reasons Why, Mr. Porter, is underprepared to face a suicidal student coping with complex trauma. Although he did not act in the scope of best practice, his failings are unfortunately not unusual among counselors, despite decades of advocacy for increased suicide assessment trainings in counselor education.

Mr. Porter missed several suicidal statements (e.g., “I need everything to stop”), made assumptions about contributing events and was uncomfortable talking about suicide (and other issues). We may easily judge Mr. Porter’s mistakes, but as counselors, we should take this opportunity to reflect and ask ourselves if we are ready to respond to a student at risk of suicide. The research is equivocal.

3) Suicide is complex and individual.

Although 13 Reasons Why portrays some known “red flags” that can indicate suicidal intent, the factors that contribute to individual suicides vary. Stressors that may influence one person’s decision to die by suicide may not have the same effect on others. For instance, we know that not all people who are depressed die by suicide (research shows the rate is from 2-15 percent) and that not all people who complete suicide are depressed. There is a variety of prevention programming regarding common warning signs. However, there is no perfect amalgam of warning signs or demographics (e.g., risk for transgender persons) that helps us differentiate who will decide to die by suicide. We need to go beyond just learning warning signs in order to help.

Livingworks, a suicide intervention training organization, focuses on three elements when assessing warning signs and risk factors. First, we must look for the meaning behind stressful events. For instance, in 13 Reasons Why, being listed “Best Ass” was highly distressing to Hannah because she felt objectified and was concerned people would misperceive her to be easy. However, another student, Angela “Best Lips” Romero, was flattered by such attention. The meaning behind the stressful event is more important than the stressful event itself.

Second, we need to know that warning signs can be, and often are, expressions of pain. When Hannah pushed Clay away, he recognized that something was wrong but did not see that her rejection was an indication of emotional pain. Third, we must trust our intuition. One peer recognizes Hannah’s poem as a cry for help but does not offer assistance. We need to pay attention to our gut feelings and act on them to take care of each other.

13 Reasons Why provides an opportunity to see Hannah’s experience of several traumatic events (cyberbullying, being stalked, public objectification, losing money, feeling responsible for a person’s death, witnessing rape and being raped) and does a good job of depicting the pain, shame and isolation she experiences as a result. The viewer has an opportunity to consider Hannah’s subjective experience and understand how the cumulative effect of these “reasons why” motivates her to suicide.

One model to help contextualize suicidality is the interpersonal-psychological theory of suicidal behavior developed by psychologist Thomas Joiner. Joiner states that the highest risk occurs when one feels like a burden to others, feels alienated or lacks belongingness and, crucially, has overcome the natural human inclination toward self-preservation. This model posits that suicide is a process — one gradually builds tolerance to the idea through self-injurious thoughts or behaviors (although each person’s path is unique). There are multiple points on that path at which others can intervene. The 13 Reasons Why series emphasizes those missed opportunities. As in Hannah’s case, every day there are suicides that happen as a result of those missed opportunities.

4) The central message is a positive one.

In the last episode, Clay says to Mr. Porter, “It has to get better, the way we treat each other and look out for each other.” Instead of feeling guilty or turning away, we can task ourselves with being more supportive community members.

All too often, we operate from a place of fear, which is understandable considering that schools have a legal duty to protect students from self-harm, and lawsuits are a potential reality (as shown in 13 Reasons Why). However, when systems or individual responders act out of fear, it focuses the interaction away from the needs of the person at risk. Even well-intentioned modern practices of “suicide gatekeeping” have substituted swift (and protocol-driven) identification and referral for the direct supportive intervention by community members proposed by John Snyder in 1971. Clay’s words echo those from Snyder half a century ago, when he said that most “who attempt suicide are victims of breakdowns in community channels for help.”

Although Mr. Porter clearly failed to proper identify Hannah’s suicidal ideation, perhaps even more troubling was his failure to hear her story and understand the factors behind her decision to die by suicide. Listening and demonstrating empathy to someone who is struggling was demonstrated to reduce suicidal ideation on calls to the National Suicide Prevention Hotline. Talking about suicide can help the person at risk to no longer focus on the past or feel alone and, instead, shift to the present moment, where the person can feel understood and cared for. If those in Hannah’s community who were witness to her emotional pain had actively engaged her and listened, it may have reduced her isolation and lessened her self-perception as a burden. This may even have prevented Hannah’s death.

Research indicates that our personal beliefs about suicide influence our responder behaviors. Therefore, gaining awareness of our beliefs and how our ability to intervene is affected by them is vital. Regardless of whether we can stop a suicide, we can control how prepared we are to try. We can make sure that our systems (in schools and elsewhere) are places where it is easy for someone to receive help.

After working through Hannah’s tapes, Clay now believes that we are, in a way, our brother’s keepers. Community-level response by direct intervention is a central theme in my (Laura Shannonhouse) research. It involves equipping “natural helpers” (e.g., teachers, bus drivers, resources officers, school counselors/psychologists) with the skills needed to perform a life-assisting suicide intervention at the moment it is needed most.

The producers and cast of 13 Reasons Why have underscored their desire for this series to start a conversation. Although that has certainly been accomplished, we hope the dialogue focuses more on how we can “look out for one another” and foster communities less at risk for suicide.



1) Graphic nature and contagion

Viewers of 13 Reasons Why watch two rape scenes and Hannah’s suicide, which is shown in detail. Nic Sheff, one of the writers of the series, stated that the scene of Hannah’s suicide was intended “to dispel the myth of the quiet drifting off.” Some crisis texts suggest that we “deromanticize” suicide by helping our clients understand the unintended effects of trying to die by suicide, such as surviving but becoming disabled or alienating friends and family. Therefore, an argument could be made that a graphic, painful portrayal of suicide is warranted.

However, research does suggest that suicide portrayals can contribute to contagion by triggering suicidal behaviors in people — particularly youth — who are experiencing high levels of emotional distress. In fact, SPRC and AFSP have made recommendations for best practices in prevention of suicide contagion. A discussion of post-suicide intervention to prevent contagion is beyond the scope of this article, but as an example, the locker memorial portrayed throughout the series is against standard guidance (it should not last for weeks, as shown). Furthermore, when considering how media reaction to the series has often included sensational headlines, it is helpful to review these recommendations for reporting on suicide.

2) Survivor’s guilt and revenge fantasies

By assigning “reasons why,” the series sends a message that Hannah’s death is caused by other people’s actions. When Clay openly questions, “Did I kill Hannah Baker?” his friend Tony answers dramatically, “Yes, we all killed Hannah Baker.”

Although we suggested earlier that we all have a responsibility to create communities that help prevent suicide, Tony’s level of direct attribution can be counterproductive. Hannah experienced multiple losses, traumas and stressors caused by others, both intentionally and unintentionally. Placing responsibility for her death on those individuals instead of on Hannah’s action can exacerbate survivors’ guilt. Those viewers who have lost a friend, loved one or acquaintance to suicide may feel even more strongly after viewing the series that “It is my fault.”

These feelings are associated with lower functioning in comparison with survivors of accidents. Although undeserved, survivor’s guilt is a real phenomenon, and considerable research shows that even counselors who experience the death of a client by suicide can experience shame/embarrassment and emotional distress.

Whereas Clay may feel guilt for his part in Hannah’s story, the tapes could implicate others in criminal or negligent behavior, perhaps giving Hannah posthumous revenge. Some viewers who may have struggled with suicidal ideation themselves could get the message that if they take their lives, they can get revenge on those who have hurt them. This is an additional reason that schools across the nation and professional helping organizations have felt the need to do damage control for 13 Reasons Why.



1) Parents need to not just talk but watch, listen and connect.

Some school counselors argue that it’s harmful for children and teens to watch the series on their own without the support of a parent or trusted adult because the series depicts a graphic and romanticized portrayal of a teenager in crisis and does not identify competent resources capable of helping her. Accordingly, many experts encourage parents to talk to their children about the series. In addition to using talking points, we recommend that parents listen deeply and without judgment to what their children say. When people feel genuinely heard, they are more likely to talk about their true thoughts and feelings.

To accomplish this goal, parents can use active listening skills, such as open-ended questions, reflections of feeling, paraphrasing and encouragement. Also, we recommend that parents watch the series and risk being human — risk being impacted by the series and empathizing with their child. The construct of empathy is powerful, particularly if it is sincere. For a three-minute visual summary, consider watching Brene Brown on empathy. In our counseling skills courses, we often talk about “getting in the well of despair” and genuinely connecting with others. We know that talking about suicide paradoxically provides a significant buffer to suicidal action.

2) We need more than prevention programming in schools.

We know from a well-regarded U.S. Air Force study that we need suicide programing at all three levels: prevention, intervention and post-intervention. Many suicide prevention programs have been implemented in the school context, but there is mixed evidence of their effectiveness. From our clinical experience in crisis response, our scholarship and our history with training a specific model of suicide intervention, we need to acknowledge that we are biased about what types of programming should be implemented and when is the right time to implement. We feel that an appropriate first step for a school system is to implement basic screeners and gatekeeper trainings such as Signs of Suicide or Sources of Strength.

However, suicide prevention should not end with identification for referral. Optimally, the process continues by assessing level of risk, identifying reasons for dying and reasons for living, discussing alternatives to dying, enlisting the support of trusted loved ones and limiting access to lethal means or securing the person’s environment. Because youth who struggle with thoughts of suicide often seek out the support of those they trust rather than professional mental health providers, those teachers, coaches and others with open hearts and doors are the most effective gatekeepers for a system. Their nondirection and empathy are useful pedagogical qualities and vital to effective suicide intervention.

We endorse models that empower those “natural helpers” to provide a potentially life-saving intervention for students who are in suicidal distress. Although this may be augmented with the support and follow-up of a trained mental health provider, gatekeepers can implement the steps listed above.

3) Be intentional about identifying caregivers and shifting school culture.

My (Shannonhouse) research involves partnering with school districts and superintendents (in Maine and Georgia) to identify “natural helpers” and equip them with the skills to perform a life-assisting intervention in the moment (i.e., Applied Suicide Intervention Skills Training, or ASIST). These natural helpers are often teachers, resource officers, coaches, administrative staff, bus drivers and other people who are likely to be confidants to students who experience distress. Measuring suicide intervention skills and responder attitudes is easy for an academic. Identifying those school personnel in the trenches who would be first responders is more difficult — it requires the total involvement of administrators. Furthermore, such an approach requires schools to commit to a student-centered response model.

ASIST is relationship-driven and aligned with the values of the helping professions. It meets the needs of students who are at risk by focusing on responding to those immediate needs rather than referring the student (which can lead to further isolation and an increased sense of burdensomeness). Although the student is often referred for more long-term counseling, ASIST provides the student with a six-step intervention at the moment it is most needed and can be performed by anyone over age 18. Having natural helpers trained in ASIST or a similar protocol can dramatically increase a school’s responsiveness and effectiveness to help students in distress.

4) Use an intervention model backed by research.

ASIST is a 14-hour, two-day, internationally recognized and evidence-based model that has been adopted by multiple states and the U.S. Army. It has also been recognized by the CDC and used in crisis centers nationwide. Caregivers trained in ASIST consistently report feeling more ready, willing and able to intervene with a person at risk of suicide.

The program has been evaluated in a variety of settings (click to download), with pretest to post-test improvement noted in trainees’ comfort level at intervention and in their demonstrated intervention skills in response to simulated scenarios. Although outcome research is rare, research compared ASIST-trained counselors with those trained in other models through a double-blind, randomly controlled study of more than 1,500 calls to the National Suicide Prevention Lifeline. Those trained in ASIST more often demonstrated particular behaviors such as exploring invitations, exploring reasons for living, recognizing ambivalence about dying and identifying informal support contacts. Those trained in ASIST also elicited longer calls.

We found that ASIST can be applied to both university and K-12 settings. Our work measured increased suicide intervention skills and beneficial responder attitudes, which have been maintained over time. We have trained more than 500 people in ASIST and have received multiple reports of teachers disarming fully formed suicide plans with their new skills. More recently, we have conducted behavioral observations of ASIST responder behavior and have begun evaluating outcomes of students who have received ASIST intervention. Initial results have been promising, including better coping and commitment to follow-up and decreased lethality.



Although 13 Reasons Why gives us pause for its poor portrayal of effective suicide intervention, we feel that the series raises awareness and, at its core, advocates a community-level response to suicide prevention. This message to “look out for each other” is aligned with more intervention-oriented gatekeeping. We have explored the impact of one such model, ASIST, in several educational settings and found that it improves responder behavior. Furthermore, this approach comes with a mindset that systems can harness their strengths (i.e., natural helpers) to focus on responding to and intervening with the student rather than simply identifying and referring the student to the system.




Please contact me (Laura Shannonhouse) should you have any questions about our research.



Laura Shannonhouse is an assistant professor in the Counseling and Psychological Services Department at Georgia State University. Her research interests focus on crisis intervention and disaster response, particularly involving social justice issues in this context. Currently, she is conducting community-based research in K-12 schools (suicide first aid) to prevent youth suicide and with disaster-impacted populations in fostering meaning-making through one’s faith tradition (spiritual first aid).


Julia L. Whisenhunt is an associate professor of counselor education and college student affairs at the University of West Georgia. She specializes in the areas of self-injury, suicide prevention and creative counseling. She is particularly interested in the relationship between self-injury and suicide and ways that mental health professionals can apply this knowledge to clinical intervention.


Dennis Lin is an assistant professor at New Jersey City University, with areas of expertise in play therapy, child/adolescent counseling and assessment, suicide prevention/intervention, quantitative research and meta-analysis. He is also a certified master trainer of Applied Suicide Intervention Skills Training (ASIST).




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Getting unstuck

By David Flack March 28, 2016

Andrew never knew his father. At age 4, he witnessed the death of his mother from an overdose. She was heroin dependent, and they were living in a car at the time. After her death, Andrew entered the foster care system. Between the ages of 4 and 15, he experienced more than a dozen different placements. Not surprisingly, with each move, his behavior became increasingly problematic.

At age 9, Andrew started drinking alcohol. By age 11, he was using alcohol and marijuana regularly. He discovered meth as a 13-year-old and went to inpatient care for the first time. He ran away after four days. When he was 15, he ran from the group home where he was living.

When Andrew entered treatment at age 16, he was on probation and had just moved into a transitional living program after several months on the streets. When he started treatment, he met Branding-Images_Unstuckthe criteria for multiple substance use disorders. He also had pre-existing mental health diagnoses that included posttraumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder, conduct disorder and major depressive disorder. At that time, Andrew said he had no interest in stopping his substance use because “that’s not a problem for me.”

In his treatment journal, Andrew wrote, “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything’s there, because I just can’t escape it no matter what I try. It’s black there, because that’s what black holes are, right? But black is really all the colors at once, every single one of them. And that’s too many damned colors if you ask me.”

Understanding the stuckness

Very few teenagers enter substance abuse treatment by choice. They show up due to legal mandates, school requirements, family pressure or other external reasons. Often they see treatment as the least bad choice — only slightly better than detention, suspension or homelessness. Like Andrew, these teens often appear unwilling or unable to do things differently, even though their current behaviors are clearly causing problems. In other words, they’re stuck.

I propose that our primary task as counselors is to help these teens get unstuck — not behave better, fulfill mandates or even stop using substances. We can hope those other things happen. I certainly do. However, it seems to me that those changes can occur only when an individual gets unstuck.

When helping teens get unstuck, we need to maintain a developmental perspective as counselors. Various developmental models exist, with most including a progression of stages that individuals move through, and each stage featuring specific tasks to be accomplished. The primary stage-specific tasks for adolescence are generally considered to be developing identity and establishing autonomy. As part of establishing autonomy, it is normal for adolescents to question, rebel against and ultimately reject the plans of authority figures, including the most well-intended plans of professional helpers.

Sometimes, those well-intended plans lead to reactance, which is a tendency to resist influences perceived as a threat to one’s autonomy. Many adolescent treatment programs are designed in ways likely to exacerbate reactance. We tell adolescents what, when, why and how. In residential programs, we restrict personal items. In wilderness programs, we often take away everything. Then we wonder why participants are unsuccessful. Worse, we blame them — declaring them in denial, resistant to treatment, unwilling to engage or simply noncompliant. Instead of helping, we’ve increased their stuckness.

Reactance can be exacerbated by what I think of as developmental debt. Most developmental theories state that if a person doesn’t successfully complete the tasks for a specific stage, then he or she remains in that stage. It seems to me that this might not be accurate. Instead, sociocultural and biological factors keep pushing individuals forward, even when tasks at another stage are unresolved or only partially completed.

With every push forward, an individual becomes less likely to complete the next stage. This leads to an ever-growing developmental debt. Much like with a credit card that’s never fully paid off, the person not only will always have a balance due, but he or she will get further behind each month.

With this developmental perspective in mind, I propose five strategies for fostering change with teenagers who have co-occurring disorders. Inspired by motivational interviewing, stages of change, narrative approaches and existential psychotherapy, I have found these strategies useful for helping this population to overcome rigid thinking, get unstuck and start moving forward.

Slow down

Traditionally, drug treatment programs have assumed that anyone entering services is ready to get and stay clean. This simply isn’t true. Change is a process, not an event. When we slow down, we’re able to help participants move through that process. Developed by James Prochaska, John Norcross and Carlo DiClemente, the stages of change is an evidence-based transtheoretical model that identifies five steps in the process of change:

  • Precontemplation: The person doesn’t believe he or she has any problems related to the target behavior, so the person sees no reason to make changes. To help participants in this stage, we can focus on building a therapeutic alliance, validate the participant’s lack of desire to change and provide objective information.
  • Contemplation: The person is considering the possibility that a problem might exist but hasn’t yet decided if change is necessary. To help participants in this stage, we can explore the pros and cons of continuing to use substances, gently identify contradictions, help make links between substance use and mental health challenges, and provide opportunities to imagine or experience alternatives.
  • Preparation: The person has identified a problem related to the target behavior and is deciding what to do next. To help participants in this stage, we can encourage small initial steps or experiments, continue to explore and solidify motivation for change, and help eliminate obstacles to change.
  • Action: The person has decided to change the target behavior, has developed a plan and is now putting that plan into action. To help participants in this stage, we can explore ways to implement change, provide support, build self-efficacy and remain solution focused.
  • Maintenance: When the new behavior has become habit, the person has entered this stage. I propose that six months of sobriety is a good milestone for this. To help participants in this stage, we can provide ongoing support, continue to explore real or perceived obstacles and foster resiliency.

In addition to these five stages, there’s Recycle, which occurs when a participant reverts to behaviors from an earlier stage. When a participant recycles, many helpers blame the person’s lack of skills, situational factors or unwillingness to change. Extenuating circumstances may certainly be present, but it seems to me that recycles occur because we push participants into the action stage too quickly. As such, recycles are potent reminders that we should slow down and revisit earlier stages, looking for unfinished or overlooked business.

Identify their motivators

Teens often enter services believing that they’re free of problems or that their only problem is something external. It may not seem like success to some, but the change process has begun when teens report treatment as the least bad option, state that their only problem is that others think there’s a problem or make similar comments. These may not be the motivators we desire for participants, but change requires meeting them where they are at, not where we want them to be.

We can help clients discover and deepen their motivators by using the “Five R’s” from William Miller and Stephen Rollnick’s motivational interviewing:

  • Relevance: Why is change important?
  • Risks: What are the risks of changing? What are the risks of not changing?
  • Rewards: What will you gain from change?
  • Roadblocks: What are the obstacles to change?
  • Repetition: Review these elements at each session.

Sometimes, to help participants solidify their motivators for change, we need to assist them in developing problem-recognition skills. We can do this by exploring what defines a problem; nurturing mindfulness; and creating an inclusive, nonjudgmental treatment environment.

Approaches from narrative therapy can also be helpful. Teens with co-occurring disorders typically enter treatment with problem-saturated stories. These tales of stuckness have become the defining stories for their lives. Help them discover new stories and further increase problem-recognition skills by:

  • Externalizing the problem: Instead of “having” a problem or “being” a problem, assist participants to view problems as existing outside themselves. This helps remove pressures rooted in blame, shame and defensiveness. Take
    this even further by encouraging participants to think of problems as characters in their stories.
  • Seeking exceptions: We build and sustain problem-saturated stories by ignoring times when the problem wasn’t in control. Seeking exceptions involves assisting participants to discover those ignored times. These exceptions hold
    the keys to change, so explore them in great detail.
  • Reauthoring stories: Once exceptions have been discovered, participants can start reauthoring their problem-saturated stories. Reauthoring gives them the opportunity to create new, more empowering stories with plots that focus on moving forward.

Some teenagers are so stuck that they’re unable to identify any exceptions to their problem-saturated stories. In these cases, it can be useful for counselors to add a fourth approach to those cited previously: creating exceptions. One way for these teens to break the cycle of stuckness is to try something new. I’ve had participants explore belly dancing, glass blowing, rock climbing, rugby, hand drumming and much more.

Expect ambivalence

As I’ve noted, the change process has begun when a teen’s thinking moves from “I don’t have a problem” to “My only problem is that other people think there’s a problem.” When this occurs, the participant has moved into the contemplation stage of change. This stage is about ambivalence, which can be defined as simultaneously believing two seemingly contradictory ideas.

Ambivalence is common for all teenagers, who desire the privileges of adulthood while retaining the comforts of childhood. In the case of substance-using teens, there is often another, more complex layer — wanting to fix their problem while continuing to use. Andrew described this ambivalence well: “Using has really messed up my life, but I don’t think I’ll ever stop. When I’m high, the bad feelings go away. I don’t think about the past, and I don’t care about the future. For a little while, my brain shuts up and I can pretend everything’s OK.”

Some professional helpers focus solely on the reasons to stop using, perhaps believing that any discussion about the possible benefits of drug use will be seen as an endorsement. This simply isn’t true. Helping youth such as Andrew get unstuck requires a sincere, nonjudgmental exploration of both the pros and the cons of substance use. Here are a few other ideas for resolving ambivalence:

  • Normalize the process. Change is hard. It conflicts with deeply ingrained behavioral patterns and neural pathways. It requires us to ignore the stories we tell about who and what we are. It requires us to face the unknown. Because change is hard, we’d rather stick to the known, even when it is not effective or useful anymore. Helping participants realize that ambivalence is common can be essential to helping them get unstuck.
  • Explore the risks of changing. High-risk behavior is common in the lives of many teens with co-occurring disorders. Paradoxically, these teens are often risk avoidant. As Prochaska, Norcross and DiClemente noted in 1994, change “threatens our very identity and asks us to relinquish our way of being.” This is dangerous stuff for anyone, but for stuck teens, it can feel especially risky. Helping them make lasting change requires exploring the risks involved.
  • Foster self-efficacy. Albert Bandura wrote that self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations.” In other words, it is a person’s belief in his or her ability to succeed. Teens with low self-efficacy avoid challenging tasks, focus on negative outcomes and quickly lose confidence in their ability to be successful. They have very little interest in attempting to change.
  • Disrupt rigid thinking habits. Teens with co-occurring disorders typically exhibit all-or-nothing thinking, catastrophize, deny having problems and blame others. These rigid thinking patterns reinforce their ambivalence. Resolving ambivalence requires them to think between the extremes. Traditional cognitive behavioral approaches identify these thinking patterns as irrational, erroneous and maladaptive. I prefer the term thinking habits, because habits can be changed.
  • Address existential concerns. Irvin Yalom identified four “givens” that define an existential perspective to psychotherapy: death, meaninglessness, freedom and isolation. Professional helpers sometimes shy away from these existential concerns, especially when working with adolescents. However, these givens are very much present in the lives of teens and can contribute significantly to both stuckness and ambivalence. Acknowledge these givens and explore them with participants.

Become trauma-informed

The Substance Abuse and Mental Health Services Administration defines trauma-informed care as “an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives.” Trauma-informed care includes the use of carefully developed approaches that reduce the likelihood of retraumatizing participants while integrating safety, trustworthiness, choice, collaboration and connection into all interactions.

Studies show that as many as 75 percent of teens in treatment for substance use disorders have experienced some form of traumatic stress. This occurs when an individual is exposed to a potentially traumatizing event or situation that overwhelms his or her ability to cope. Traumatic stress can be caused by a one-time experience or complex trauma, which can be defined as the experience of multiple traumatic events. Traumatic stress can lead to PTSD, a severe anxiety disorder that develops after exposure to traumatic stress. PTSD is a clinical diagnosis that requires the presence of specific symptoms, such as nightmares about the traumatic event, avoidance of stimuli associated with the event, increased arousal and hypervigilance. Regardless of whether they meet the diagnostic threshold for PTSD, teen trauma survivors often exhibit the following:

  • Hyperarousal: Survivors can become extremely vigilant about their surroundings and often experience high levels of anxiety, which leads to sleep problems, trouble concentrating, feeling constantly on guard or being easily startled.
  • Intrusion: Memories, flashbacks, and nightmares can continue long after the original traumatic exposure. Additionally, survivors sometimes unintentionally reenact aspects of the trauma. For example, teen survivors often engage in highly risky behaviors.
  • Constriction: Attempts to avoid intrusion frequently result in survivors withdrawing from the world both physically and emotionally. Agoraphobia, substance use, limited social interactions and dissociation are a few examples of constriction.

When an individual has both a substance use disorder and traumatic stress, we usually assume that the trauma led to using the substance. However, substance use often leads to trauma exposure — or further exposure. In addition, pre-existing mental health challenges and a variety of other factors can increase the likelihood of trauma exposure. Whether trauma leads to drug use, drug use leads to trauma or a more complex scenario is present, substance-abusing survivors often find themselves perpetually stuck.

Even though risky behavior is evident in the lives of most substance-abusing teens, and especially those with trauma histories, these youth are frequently risk adverse, with their risky behaviors serving as ineffective attempts to avoid risk or distractions from their past trauma. Some adolescent survivors are so obsessed with safety that they resort to substances and other maladaptive methods in an effort to find it. Still other teens lead lives so constricted that they barely participate in life. According to Judith Herman, in all these cases, trauma has “cast the victim into a state of existential crisis” in which all choices likely lead to even further stuckness.

Create connectedness

Edward Hallowell wrote that connectedness “is a sense of being a part of something larger than oneself. It is a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone. … Connectedness is my word for the force that urges us to ally, to affiliate, to enter into mutual relationships, to take strength and to grow through cooperative behavior.”

For teens with co-occurring disorders, this sense of connectedness is typically missing. I believe that isolation exacerbates all life problems, so I strongly propose that the first step toward ensuring a valuable therapeutic experience is helping participants move toward increased connectedness. In clinical settings, we can focus on two types of connectedness: group cohesion and therapeutic alliance.

Group cohesion: It seems to me that groups should be part of the treatment plan for any teen with co-occurring disorders. That said, for change to happen in groups, a strong sense of cohesion is essential. We can help achieve group cohesion by remembering this simple formula: Cohesion = Shared Fun + Safety.

When working in groups, it is essential that we create safe spaces. This includes physical, emotional and social safety. We can create a sense of safety by modeling what we expect. That means being consistent and reliable, treating participants and co-facilitators in a welcoming manner and ensuring that groups are fully inclusive.

Some treatment approaches seem to assume that participants are fragile, hopelessly damaged or completely dysregulated. Fun activities and laughter have no place is such approaches. That’s a shame. Shared fun activities build connectedness between group members and provide valuable opportunities to practice interpersonal skills. In addition, the use of fun and games helps alter negative preconceived notions of treatment, provides entry points for less verbal participants and helps teens reauthor their stories to include a world where laughter is the norm.

Therapeutic alliance: Numerous studies show that a strong therapeutic alliance is the most important indicator of positive outcomes when working with teens. When we take time to foster a strong alliance by genuinely embracing our participants’ real motivators, we stop being an adversary and become an ally. This allows us to gently challenge the ambivalence, thinking habits and other roadblocks that keep participants stuck.

Edward Bordin wrote that a strong therapeutic alliance is composed of three elements: a positive bond between the therapist and participant, agreement regarding the tasks of treatment and agreement about the goals of treatment. In other words, there is congruence between the participant and the therapist. It seems to me that there also exists a need for transparency. Here are a few ideas for this:

  • Explain what you’re doing as a counselor. Take time to explain the theory behind your therapeutic approaches. In addition, explain to the teen what you hope to achieve by asking a particular question or assigning a specific homework task. This not only increases transparency but also improves buy-in.
  • Remember that relationships are reciprocal. We expect participants to be honest. They should get the same from us. Don’t disclose excessive amounts of personal information, but do answer questions that have been sincerely asked. Be genuine and model openness.
  • Use concurrent documentation. Before ending individual sessions, write your progress note. Then have the participant read the progress note and write his or her own summary of the session. This may seem a bit clumsy at first, but in my experience, most participants quickly embrace the process.

Addiction as an attachment disorder 

Substance abuse specialists familiar with attachment theory invariably report an inverse relationship between substance use disorders and healthy interpersonal attachments. In traditional treatment, unhealthy interpersonal attachments are generally considered the result of addiction. There is no doubt that heavy substance abuse is likely to exert a negative influence on relationships. However, there is mounting evidence that insecure attachment styles are risk factors for problematic substance use.

There are two basic concepts that are important for us to consider. First, if we don’t have opportunities to observe caregivers engaging in effective emotional regulation, we may resort to substances in an effort to manage uncomfortable feelings. Second, if we don’t connect to other people in meaningful, emotionally satisfying ways, we will find something else to fill that void.

Andrew referred to this void as a black hole made of all colors and tried to fill it with alcohol, drugs and significant acting-out behaviors. Other teens try to fill their voids with gangs, gambling, food, sex or video games. When we slow down and meet participants where they are at, we are able to help them get unstuck and start the change process so that they can see all the colors, not just black.




Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

David Flack is a licensed mental health counselor, chemical dependency professional and child mental health specialist. He lives in the Seattle area and has worked for the past dozen years exclusively with teenagers who have co-occurring disorders. He has special interests in the comorbidity of substance use and trauma in adolescents, the use of experiential learning in clinical settings and the unique challenges faced by LGBTQ teens. Contact him at david@davidflack.com.

Letters to the editorct@counseling.org



Do preteens still play in counseling?

By Mark Loewen December 10, 2015

As a play therapist, I’m used to explaining the ins and outs of play therapy. Because play is a universal concept, most people understand that it is also a child’s “language” and can be used to address many issues in therapy. However, when it comes to preteens, play therapy takes a slight shift.

Whereas children don’t always have the ability to articulate their thoughts and feelings, preteens are becoming more able to hold conversations about important issues. They can still become very uncomfortable, however, if they have to sit across from an adult for a “serious” talk. Plus, by the time most preteens come to counseling, they’ve heard a lot of talking already.

Play is still very important to preteens, although it starts to look a little different. As children mature, activities move away from fantasy play to more structured games. Still, children of this age often feel trapped between childhood and the teen years. In play therapy, preteens often vacillate between play that is more common to younger children and activities that appeal more to teenagers.

At our counseling practice, we often use games and interactive activities to take the pressure off. Preteens enjoy both regular board and card games and also specialized therapeutic games. Games can be used to deal with anxiety, power and control issues, self-esteem, relationships and difficult behaviors. Specialized therapeutic games address topic areas such as depression, anger, anxiety, aggression, life changes, coping skills and much more. Skilled play therapists can use almost any game to address difficult issues with children and teenagers.

Preteens are also developing creative skills. They are moving into using abstract thought as life opens up to endless possibilities. Expressive arts are a great tool to address new thoughts and feelings. Using specific art materials, clients build, sculpt or draw to represent their struggles and find alternative solutions.

Preteens also enjoy using the sand tray and an array of miniatures to represent their “worlds.” Using miniatures provides a feel that is similar to setting up toys. At the same time, the child is using these

Image via Wikimedia Commons

Image via Wikimedia Commons

miniatures with a few guidelines that make the activity feel challenging. Sand tray therapy is a great way to allow kids in early adolescence to work through their issues without feeling pressured or judged.

Additionally, interactive activities can be used to teach mindfulness meditation skills. By learning to direct their breathing and use creative imagery, kids become more aware of their feelings and what’s behind them. By recognizing intense emotions, they are better able to control them and listen to what these feelings are trying to say to them.

In conclusion, preteens are balancing child’s play and teen activities. Given enough freedom, children of this age group may allow themselves to delve into pretend play, dressing up or other activities that are more typical for younger children. On the other hand, they also like the challenge of activities that are considered to be more grown-up. Maintaining this balance requires their counselors to maintain a great level of flexibility and a nonjudgmental attitude. As a result, preteens will know that counseling is a place where they can use any of their internal resources at any time to address any issue at hand.



Mark Loewen is a licensed professional counselor, registered play therapist and parent coach in Richmond, Virginia. He is the owner of LaunchPad Counseling (launchpadcounseling.com), a practice that helps children, teens and parents cultivate their inner resources to overcome stressful circumstances. Contact him at mark@launchpadcounseling.com.


Assessing ‘ideal’ versus ‘real’ family characteristics with adolescents

By Brandon S. Ballantyne April 13, 2015

When working with adolescents in a group setting, it is important to provide opportunities to explore, evaluate and process the dynamics that occur within their homes. After all, eventually they will be faced with the dilemma of figuring out how to apply what they have learned in therapy to situations at home.

I have formulated a creative, psychoeducational task that allows adolescents to assess and explore the similarities and differences between their “ideals” and what really occurs within their unique and, at times, chaotic family relationships. I have broken this down into three simple categories. I ask the housedrawing_1adolescents to draw an illustration of a house. Inside the house are to be three distinct rooms with boundaries, because boundaries are healthy no matter how you slice that pie. The adolescents usually laugh at that analogy. Utilizing that humor, I then invite them to talk more about the boundaries at home.

I next ask them to label each of the three distinct rooms in the house. One section is labeled “Think,” another section is labeled “Do” and the last section is labeled “Say.”

I ask them to title their paper “Family Shoulds.” As a group, we discuss what the word “should” refers to. Typically, one group member will mention his or her impression of the word “should” as a reflection of a demand, expectation or wish. All of those definitions are acceptable for this task.

The idea is to have each group member write a list of three items for each category inside the house: three things they believe a family “should think,” three things they believe a family “should do” and three things they believe a family “should say.”

I have found that when I simplify group tasks in terms of “threes,” that the group flows more smoothly. For example, three rooms in the house and a list of three items for each of the three categories. I think this provides the task a sense of organization and predictability, thus increasing the group members’ level of trust and safety. This creates a less intimidating environment for each group member to talk about his or her family issues or other issues that may come up.

It is important to invite each group member to ask questions about the assignment. For example, I usually receive questions such as “What do you mean by things a family should say?” You might encourage the adolescents to write down specific things they believe a family should say to one another and then apply this to the other categories as well. For example, you might encourage the adolescents to write down three things they believe a family “should do together.” Or encourage them to write down a list of three things they believe a family “should think about one another.”

In the second component to this task, you instruct each group member to draw another outline of a house with the same three categories: think, say and do. Except this time, you ask the adolescents to write down their beliefs about their “Family Reals.” It is important to have a discussion about what you mean by the term “reals.” Usually, one group member will suggest that “reals” refers to facts or reality.

As the counselor, you can then take the focus of the group and place it on sharing ideas of “what actually goes on” from day to day in their families. Discuss how this is similar to or different from their beliefs about what a family “should” be doing, thinking, or saying.

This invites conversation about specific issues within their families that the adolescents want to address. You can also have a discussion about what “shoulds” are healthy versus what “should” are unhealthy. Finally, you can discuss which “shoulds” are realistic to address, identifying achievable, measurable steps to work toward at home.

As the adolescents listen to the other group members speaking about their family issues, they beginhousedrawing_2 to feel a sense of validation and belongingness. They cultivate a belief that “I am not alone.” As anyone who has studied Irvin Yalom likely knows, these three components are critical to the progress of individuals in group settings.

This task can also be used as a tool in family therapy sessions, serving as a less intimidating way to open the door to communication. It can be used to explore and address each family member’s expectations for others in the family unit.

It can be emotionally difficult for adolescents to talk directly about family issues. But as a counselor, I believe that if you can access adolescents’ creativity and provide a level of predictability, organization and safety, it will open the door to communication between you and your client. This can then be transferred to work with the family as a whole.

I believe this task creates opportunities for individual growth within the therapeutic relationship and opportunities for growth within the family system by reinforcing the difference between realistic and unrealistic expectations, discussion of problem-solving and implementation of communication skills.



Brandon S. Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor. Contact him at ballantynebrandon@yahoo.com.



The Hope Chest: Unpacking the hurt

By Kim Johancen-Walt August 19, 2014

When I first met Ally, 17, she surveyed the seating arrangement in my office and chose the chair closest to my door. Obviously guarded, she sat with both arms and legs crossed looking at me with green eyes slightly camouflaged by blond wispy bangs. Ally’s mother had been trying to get box_unpackingher to come to therapy in recent months because of Ally’s deepening depression. Her mother believed Ally’s depression was due to an abortion Ally had had several months prior to our first meeting. The mother had only insisted on therapy after reading a journal entry in which Ally had made it clear she was thinking about suicide.

As I began to ask Ally some questions during our initial visit, she stated that she did not need therapy and expressed anger at her mother for forcing her to come to my office. Although Ally knew I was aware of the journal entry and the abortion, I honored her resistance by staying in shallow waters, asking only about things such as hobbies, school and friends. I purposefully avoided the topic of loss. At first she answered questions but became increasingly quiet and then stopped talking all together. Counselors working with teens dread these moments, wondering how we will get through the hour when our young clients refuse to talk to us despite our best efforts to connect, create safety and begin the therapeutic process.

By the time many kids get to my office, they have come to believe that most of the adults in their lives cannot help them. They feel misunderstood, sometimes blamed, and tend to find their own emotion overshadowed by the emotion of others. They are also desperate for relief. I strive to educate these kids about the connections between unresolved grief, loss and suicidal behavior, about how therapy can help them manage pain differently and how to cultivate hope and resiliency along the way.

Sitting in silence, I explained to Ally that I actually did not need to know much about her to know that she was in incredible pain due to her suicidal thoughts. I told her that I knew I was looking at the tip of a very large iceberg. It is important to communicate to kids our knowledge of what may fuel suicide, that we take it seriously but are comfortable talking about it, and that we do not judge them for their thoughts and actions. I told Ally I knew she was doing the best she could to take care of herself as she dealt with unbearable pain.

Not believing that they can (or should) seek support and care from others, many kids come to believe that they must be fully self-reliant. Otherwise, they think they will risk more injury to themselves or become even more burdensome to those around them. Add to this the developmental (and oftentimes skewed) belief about the need to seek independence, and many teens retreat completely into themselves. Affected deeply by the things that happen in their lives, these teens believe they are mainly (if not solely) responsible for their losses, their pain and their inability to cope. Rather than asking for help, many of these teens become increasingly desperate as they find themselves drowning, with little or no ability to swim to the surface.


The overflow

When working with suicidal teens, I have found it useful to tell them about the invisible box that we each carry. It is a place where we store the painful events or losses in our lives, packaging them tightly to avoid the feelings associated with those events. Although this process of stuffing may work for a while, over time our boxes can begin to fill up, leaving us little room or tolerance for added stressors. I remember vividly the reaction of one of my 16-year-old male clients who, after I explained the box metaphor, stated, “If that is true, then I have a field of boxes buried in the ground.”

Once full, we find ourselves frantically trying to keep the lid on the box tightly sealed. But regardless of how hard we try, it is at this point of distress that painful content may begin to leak over the sides. When there is no room left in the box, many teens find themselves spilling over into what I term the “Overflow.” Desperate, they may turn to self-injury, substance abuse or suicidal behavior. After using this metaphor to explain the connections between my clients’ feelings and behaviors, most begin to understand the importance of making room so they can stay out of the Overflow. They become primed for therapy and ready to cautiously explore methods of healing and more effective ways of coping.

Although the unpacking is necessary, it is also a tender process. After a few sessions spent building both trust and safety, Ally started discussing the details of the abrupt and painful breakup with her boyfriend that occurred soon after her pregnancy. She cried quietly as she talked about his cruelty, along with how her mother had also abandoned her, “forcing” her to have an abortion and telling her she was irresponsible and an embarrassment to the family.

Ally believed she was fully to blame for the pregnancy, for having disappointed her parents through her reckless behavior and for her boyfriend leaving. Furthermore, she believed that her inability to cope and “just get over it” were signs of a flawed character. She believed she was weak and selfish for having aborted her baby. She continued talking about what happened, looking into the deep well of grief over having lost a child.

Throughout her process, I seized every opportunity to listen, understand and treat her with love and compassion. We discussed how her coping was outstripped trying to deal with complicated grief and that her suicidal feelings were the result of what had happened. In other words, I told her that her depression and increasing suicidal thoughts made sense.

Many of my clients have dealt with multiple losses and are unaware that each new wound can awaken others that are tucked away in dark corners. Overwhelmed with grief, most of these clients do not realize that the only way to make room is to unpack their losses one by one. And, sometimes, one explosion can be followed by several other mini blasts. For example, if our clients are not met with love, support or compassion after the initial bomb goes off, then their injuries can deepen, their framework distorted by multiple losses. They come to expect loss, perhaps blaming themselves and losing hope. Ally not only lost her child, but she also felt abandoned by some of the most important people in her life. She couldn’t stop the bleeding despite her best efforts to avoid stepping on additional land mines.


Handle contents with care

When I discuss the box metaphor with teens, I assure them that they are in charge of what content they choose to remove. Not wanting these young clients to feel further overwhelmed, it gift1is critical to move forward at a gentle pace and to focus on the importance of making room rather than what is actually emptied. After explaining the therapeutic process in this way, many kids naturally begin looking at what is taking up the most space in their containers, knowing that the bigger objects are what contribute to their inability to handle added stressors.

We do not want our clients to empty everything at once, and each container must be handled with care. I want kids to know they are in control of their therapy, but I also want them to be aware that the unpacking is necessary if they are going to make room, build tolerance and effectively stay out of the Overflow. Throughout therapy, we assess safety and coping constantly, knowing that without careful attention to the process, speed and wounds touched, we may inadvertently push our young clients closer to the edge rather than away from it. We find ourselves dipping in and out of raw material.

Through our conversations, Ally slowly began building confidence in her ability to handle painful feelings. Gradually, we were ready to invite her mother into session to discuss what had happened. Both women cried together as Ally’s mother discussed feeling deep remorse for how she had handled the situation and for not considering Ally’s feelings surrounding the abortion. Through her own accountability, Ally’s mother opened the door to begin repairing the cherished relationship between mother and daughter. And in addition to cultivating compassion for herself, Ally was able to begin finding compassion for her mother. She came to realize that her mother had also done the best she could at the time and acted in what she believed to be the best interests of her daughter.

Through therapy, we help our young clients to uncover new pathways that were previously out of their view. We celebrate their victories and watch them gain confidence not only in their ability to cope but also in their ability to heal. And as we end therapy, we remain aware that they may have more work to do. Whether they collect new losses over time or whether older losses begin to reemerge, we know that future excavation may be needed — although that process may not happen with us.

We have done our job if we have given our young clients a new framework to work through the inevitable human experience of grief and loss, if we have taught them the importance of seeking help from caring others and if we have helped them learn how to effectively stay out of the Overflow. Through our work, these teens leave therapy with a new definition of healthy independence rather than one that finds them overwhelmed and in dependence. Through our connections with caring others, we are reminded that even in times when things are not OK, we will be OK.





Kim Johancen-Walt writes “The Hope Chest” column exclusively for CT Online. She is a licensed professional counselor with almost 20 years of experience. Her clinical experience includes working as a therapist for La Plata County Human Services, where she helped develop a treatment model for adolescents in Durango, Colorado. She has presented her clinical work at mental health conferences nationally, including at the annual conference for the International Society for the Study of Self-Injury. Additional clinical experience includes a position as assistant training director and senior counselor in the Counseling Department at Fort Lewis College. She currently operates a full-time private practice in Durango. Contact her at johancenwaltks@gmail.com.


Read her previous column, “The Hope Chest: The GIFT of therapy,” here:  ct.counseling.org/2014/06/the-hope-chest-the-gift-of-therapy