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Taking a strengths-based approach to suicide assessment and treatment

By John Sommers-Flanagan and Rita Sommers-Flanagan July 7, 2021

When the word “suicide” comes up during counseling sessions, it usually triggers clinician anxiety. You might begin having thoughts such as, “What should I ask next? How can I best evaluate my client’s suicide risk? Should I do a formal suicide assessment, or should I be less direct?” In addition, you might worry about possible hospitalization and how to make the session therapeutic while also assessing risk.

Suicide-related scenarios are stressful and emotionally activating for all mental health, school and health care professionals. Counselors are no exception. But counselors bring a different orientation into the room. As a discipline, counseling is less steeped in the medical model, more oriented toward wellness, and more relational throughout the assessment and intervention processes. In this article, we explore how professional counselors can meet practice standards for suicide assessment and treatment while also embracing a holistic, strengths-based and wellness orientation.

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Moving beyond traditional views of suicide

Suicide and suicidality have long been linked to negative judgments. Sometimes suicide — or even thinking about suicide — has been characterized as sinful or immoral. In many societies, suicide was historically deigned illegal, and it remains so in some countries today. In the past, suicidality was nearly always pathologized, and that largely remains the case now. Defining suicide and suicidal thoughts as immoral or illegal or as an illness is an alienating and judgmental social construction that makes people less likely to openly discuss these thoughts and feelings. Most people experiencing suicidality already feel bad about themselves; socially sanctioned negative judgments can cause further harm.

Our position is that suicide is neither a moral failure nor evidence of so-called mental illness. Instead, consistent with a strengths-based perspective, we believe suicidal ideation is a normal variation on human experience. Suicidal ideation usually stems from difficult environmental circumstances, social disconnection or excruciating emotional pain. Improving life circumstances, enhancing social connection and reducing emotional pain are usually the best means for reducing the frequency and intensity of suicidal thoughts and feelings.

Practitioners trained in the medical model tend to diagnose people who are suicidal with some variant of depressive disorder and provide treatments that target suicidality. Sometimes treatments are applied without patient consent. Health care providers are usually considered authority figures who know what’s best for their patients.

In contrast to the medical model, a strengths-based perspective includes several empowering assumptions:

When painful psychological distress escalates, strengths-based counselors view the emergence of suicidal ideation as a normal and natural human response. Suicidal ideation is a reaction to life circumstances and may represent a method for coping with relentless psychological pain.
Because suicidal ideation is viewed as a normal response to psychological pain, client disclosures of suicidality are framed as expressions of distress, rather than evidence of illness. Consequently, if clients disclose suicidality, counselors don’t react with fear and judgment, but instead welcome suicide-related disclosures. Strengths-based counselors recognize that when clients openly share suicidal thoughts, they are showing trust, thus creating opportunities for interpersonal and emotional connection.
Many people who are suicidal want to preserve their right to die by suicide. If they feel judged by health care or school professionals and coerced to receive treatment, they may shut down and resist. Instead of insisting that clients and students “need treatment,” strengths-based counselors recognize that clients are the best experts on their own lived experiences. Strengths-based counselors provide empathic, collaborative assessment and treatment when clients and students are suicidal.
Instead of relying on mental health diagnoses or asking symptom-based questions from a standard form such as the Patient Health Questionnaire-9, strengths-based counselors weave in assessment questions and observations pertaining to client strengths, hope and coping resources. Using principles of solution-focused counseling and positive psychology, strengths-based counselors balance symptom questions with wellness-oriented content.

We believe the preceding assumptions can be woven into counseling in ways that improve traditional suicide assessment and treatment approaches. In fact, over the past two decades, evidence-based treatments for suicide, such as collaborative assessment and management of suicide, have increasingly emphasized empathy, normalization of suicidality and counselor-client collaboration. An objectivist philosophy and medical attitude is no longer required to work with clients or students who are suicidal. Newer approaches, including the strengths-based approach discussed here, flow from postmodern, social constructionist philosophy in which conversation and collaboration are fundamental to decreasing distress and increasing hope.

A holistic approach

When clients disclose suicidal ideation, it’s not unusual for counselors to overfocus on assessment. In reaction to suicidality, counselors may begin asking too many closed questions about the presence or absence of suicide risk and protective factors. This shift away from an empathic focus on what’s hurting and toward analytic assessment protocols is unwarranted for two primary reasons. First, based on a meta-analysis of 50 years of risk and protective factors studies, a research group from Vanderbilt, Harvard and Columbia universities concluded that no factors provide much statistical advantage over chance suicide predictions. In other words, even if mental health or school professionals conduct an extensive assessment of client risk and protective factors, that assessment is unlikely to offer clinical or predictive value. Second, focusing too much on suicide risk assessment usually detracts from important relationship-building interactions that are necessary for positive counseling outcomes.

Instead of overemphasizing risk factor assessment, counselors should identify client distress and respond empathically. Recognizing and responding supportively to emotional pain and distress will help individualize your understanding of the client’s unique risk and protective factors. From a practical perspective, rather than using a generic risk factor checklist, counselors are better off directly asking clients questions such as, “What’s happening that makes you feel suicidal?” and “What one thing, if it changed, would take away your suicidal feelings?”

Additionally, as strengths-based practitioners, we should be scanning for, identifying and providing clients feedback on their unique positive qualities. Statements such as “Thank you so much for being brave enough to tell me about your suicidal thoughts” communicate acceptance and a reflection of client strengths. Although counselors may work in settings that use traditional suicide risk assessment protocols, they can still complement that procedure with a more holistic, positive and interpersonally supportive assessment and treatment planning process.

To help counselors tend to the whole person — instead of overfocusing on suicidality — we recommend using a dimensional assessment and treatment model. Our particular dimensional model tracks and organizes client distress into seven categories. Here, we describe each dimension, offer examples of how distress manifests differently within each dimension, and identify evidence-based or theoretically robust interventions that address dimension-specific distress.

The emotional dimension: Clients who are suicidal often experience agonizing sadness, anxiety, guilt, shame, anger and other painful emotions. Other times, clients feel numb or emotionally drained. Focusing on and showing empathy for core emotional distress or numbness is foundational to working with these clients. Clients also may experience emotional dysregulation. Interventions to address emotional issues in counseling include traditional cognitive behavioral therapies for depression and anxiety, existential exploration of the meaning of emotions, and dialectical behavior therapy to aid clients in emotional regulation skill development.

The cognitive dimension: Humans often react to emotional pain with maladaptive cognitions that further increase their distress. Hopelessness, problem-solving impairments and core negative beliefs are linked to suicide. Depending upon each client’s unique cognitive symptoms and distress, strengths-based counselors will begin by responding with empathy and then, if needed, work with hopelessness in the here and now as it emerges in session. Counselors may also initiate problem-solving strategies, emphasize solution-focused exceptions and teach clients how to notice, track and modify maladaptive thoughts.

The interpersonal dimension: Substantial research points to social and interpersonal difficulties as factors that drive people toward suicide. Common interpersonal themes that trigger suicidal distress include social disconnection, interpersonal grief and loss, social skills deficits, and repetitive dysfunctional relationship patterns. Interventions in the interpersonal dimension include couple or family counseling, grief counseling, social skills training, and other strategies for enhancing social and romantic relationships.

The physical dimension: Physical symptoms trigger and exacerbate suicidal states. Common physical symptoms linked to suicide include agitation/arousal, physical illness, physical symptoms related to trauma, and insomnia. Using a strengths-based model, counselors can collaboratively develop treatment plans that directly address physical symptoms. Specific interventions include physical exercise, evidence-based trauma treatments, and cognitive behavior therapy for insomnia.

The cultural-spiritual dimension: Cultural practices and beliefs alleviate or contribute to client distress and suicidality. Religion, spirituality and a sense of purpose or meaning (or a lack thereof) powerfully mediate suicidality. Specific cultural-spiritual themes that trigger distress include disconnection from a community, higher power or faith system. A sense of meaninglessness or acculturative distress may also be present. Strengths-oriented counselors explore the cultural-spiritual and existential issues present in clients’ lives and develop individualized approaches to addressing these deeply personal sources of distress and potential sources of support or relief.

The behavioral dimension: Clients and students sometimes engage in specific behaviors that increase suicide risk. These may include alcohol/drug use, impulsivity and repeated self-injury. Having easy access to guns or other lethal means is another factor that increases risk. Helping clients recognize destructive behavior patterns, develop alternative coping behaviors and decrease their access to lethal means can be central to a holistic treatment plan. Additionally, collaborative safety planning is an evidence-based suicide intervention that focuses on positive coping behaviors.

The contextual dimension: Many larger contextual, environmental or situational factors contribute to distress in the other six dimensions and thus heighten suicidality. These factors include poverty, neighborhood or relationship safety, racism, sexual harassment and unemployment. Helping clients recognize and change contextual life factors — if they have control over those factors — can be very empowering. Clients also need support coping with uncontrollable stressors. Developing an action plan and discerning when to use mindful acceptance may be an important part of the counseling process. Advocacy can be particularly useful for supporting clients as they face systemic barriers and oppression.

Suicide competencies

Regardless of theoretical orientation or professional discipline, mental health and school professionals must meet or exceed foundational competency standards. In this article, we recommend integrating strengths-based principles, holistic assessment and treatment planning, and wellness activities into your work with individuals who are suicidal. Our recommendation isn’t intended to completely replace traditional suicide-related practices, but rather to add strengths-based skills and holistic case formulation to your counseling repertoire.

When adding a strengths-based perspective into one’s counseling repertoire, counselors should remain cognizant of the usual and customary professional standards for working with suicide. The American Counseling Association’s current ethics code doesn’t provide specific guidance for suicide assessment and treatment. However, suicide-related competencies are available in the professional literature. For example, Robert Cramer of the University of North Carolina Charlotte distilled 10 essential suicide competencies from several different health care and mental health publications, including guidelines from the American Association of Suicidology.

Cramer’s 10 suicide competencies are listed below, along with short statements describing how strengths-based counselors can address each competency.

1) Be aware of and manage your attitude and reactions to suicide. Strengths-based counselors strive for individual, cultural, interpersonal and spiritual self-awareness. Self-care also helps counselors stay balanced in their emotional responses to clients who are suicidal.

2) Develop and maintain a collaborative, empathic stance with clients. Strengths-based counselors are relational, collaborative and empathic, while also consistently orienting toward clients’ strengths and resources.

3) Know and elicit evidence-based risk and protective factors. Strengths-based counselors understand how to individualize risk and protective factors to fit each client’s unique risk and protective dynamics.

4) Focus on the current plan and intent of suicidal ideation. Strengths-based counselors not only explore client plans and intentions but also actively engage in conversations about alternatives to suicide plans and ask clients about individual factors that reduce intent.

5) Determine the level of risk. Strengths-based counselors engage clients to obtain information about self-perceived risk and collaborate with clients to better understand factors that increase or decrease individual risk.

6) Develop and enact a collaborative evidence-based treatment plan. Strengths-based counselors engage clients in establishing an individualized safety plan that includes positive coping behaviors and collaboratively develop holistic treatment plans that address emotional, cognitive, interpersonal, cultural-spiritual, physical, behavioral and contextual life dimensions.

7) Notify and involve other people. Strengths-based counselors recognize the core importance of interpersonal connection to suicide prevention and involve significant others for safety and treatment purposes.

8) Document risk assessment, the treatment plan and the rationale for clinical decisions. Strengths-based counselors follow accepted practices for documenting their assessment, treatment and decision-making protocols.

9) Know the law concerning suicide. Strengths-based counselors are aware of local and national ethical and legal considerations when working with clients who are suicidal.

10) Engage in debriefing and self-care. Strengths-based counselors regularly consult with colleagues and supervisors and engage in suicide postvention as needed.

The strengths-based approach in action

Liam was a 20-year-old cisgender, heterosexual male with a biracial (white and Latino) cultural identity. At the time of the referral, Liam had just started a vocational training program in the diesel mechanics trade through a local community college. He was referred to counseling by his trade instructor. About a week previously, Liam had experienced a relationship breakup. Subsequently, he punched a wall while in class (breaking one of his fingers), talked about killing himself, threatened his former girlfriend’s new boyfriend, and impulsively walked off the job at his internship placement.

Liam started his first session by bragging about punching the wall. He stated, “I don’t need counseling. I know how to take care of myself.”

Rather than countering Liam’s opening comments, the counselor maintained a positive and accepting stance, saying, “You might be right. Counseling isn’t for everyone. You look like you’re quite good at taking care of yourself.”

Liam shrugged and asked, “What am I supposed to talk about in here anyway?”

Many clients who are feeling suicidal immediately begin talking about their distress. Others, like Liam, deny suicidality. When clients lead with distress, the counselor’s first task is to empathically explore the distress and highlight unique factors in the client’s life that trigger suicidal thoughts and impulses. In contrast, with Liam, the counselor mirrored Liam’s opening attitude, accepted Liam’s explanation and explicitly focused on Liam’s strengths: his employment goals, his initiative to start vocational training immediately after graduating high school, his ability to care deeply for others (such as his ex-girlfriend), and his pride at being physically fit.

After about 15 minutes, the conversation shifted to how Liam made decisions in his life. Instead of questioning Liam’s judgment, the counselor continued a positive focus, saying, “As I think about your situation, in some ways, hitting the wall was a good idea. It’s definitely better than hitting a person.” The counselor then added, “I don’t blame you for being pissed off about breaking up. Nobody likes a breakup.”

The counselor asked Liam to tell the story of his relationship and the events leading to the breakup. Liam was able to talk about his sense of betrayal and loneliness and his underlying worries that he’d never accomplish anything in life. He admitted to occasional thoughts of “doing something stupid, like offing myself.” He agreed to continue with counseling, mostly because it would look good to his vocational training instructor. Before the session ended, the counselor explained that counselors always need to do a thing called “a safety plan.” During safety planning, Liam admitted to owning two firearms, and even though he “didn’t need to,” he agreed to store his guns at his mom’s house for the next month.

After the first session, the counselor documented the assessment, the intervention and Liam’s treatment plan. The counselor’s documentation included problems and strengths, organized with the holistic dimensional model:

1) Emotional: Liam experienced acute emotional distress and emerging suicidal ideation related to a relationship breakup. Although he minimized his distress, Liam was also able to articulate feelings of betrayal and loneliness.

2) Cognitive: Liam felt hopeless about finding another girlfriend. He was somewhat evasive when asked about suicidal ideation. Eventually, he acknowledged thinking about it and that if he ever decided to die (which he said he “wouldn’t”), he would shoot himself. Liam was able to participate in problem-solving during the session.

3) Interpersonal: Although Liam was distressed about the breakup of his romantic relationship, he agreed to consult with his counselor about relationships during future sessions. He collaboratively brainstormed positive and supportive people to contact in case he began feeling lonely or suicidal. Liam reported a positive relationship with his mother.

4) Physical: Liam reported difficulty sleeping. He said, “I’ve been drinking more than I need to.” During safety planning, Liam agreed to specific steps for dealing with his insomnia and alcohol consumption. Liam was in good physical shape and was invested in his physical well-being.

5) Cultural-spiritual: Liam said that “it won’t hurt me any” to attend church with his mom on Sundays. He reported a good relationship with his mother. He said that going to church with her was something she enjoyed and something he felt good about.

6) Behavioral: Liam contributed to writing up his safety plan. He agreed to follow the plan and take good care of himself over the coming week. Liam identified specific behavioral alternatives to drinking alcohol and suicidal actions. He agreed to store his firearms at his mother’s home.

7) Contextual: Other than high unemployment rates in his community, Liam didn’t report problems in the contextual dimension. He said that he currently had an apartment and believed he had a good employment future.

Concluding comments

A holistic, strengths-based and wellness-oriented model for working with clients and students who are suicidal is a good fit for the counseling profession. In tandem with knowledge and expertise in traditional suicide assessment and treatments, the strengths-based model provides a foundation for suicide assessment and treatment planning. A detailed description of the strengths-based model is available in our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach, which was published earlier this year by ACA.

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John Sommers-Flanagan is professor of counseling at the University of Montana with over 100 professional publications, including Suicide Assessment and Treatment Planning, Clinical Interviewing and seven other books co-authored with Rita Sommers-Flanagan. Contact him at john.sf@mso.umt.edu or through his blog, which also offers free counseling-related resources, at johnsommersflanagan.com.

Rita Sommers-Flanagan is professor emerita of counseling at the University of Montana. Since retiring, Rita has shifted her interests toward suicide prevention, positive psychology, creative writing and passive solar design. She blogs at godcomesby.com/author/ritasf13 and can be contacted at rita.sf@mso.umt.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

The use of evidence-based practices with oppressed populations

By Geri Miller, Glenda S. Johnson, Mx. Tuesday Feral, William Luckett, Kelsey Fish and Madison Ericksen December 3, 2018

Therapy must always be tailored to the individual; there is no one-size-fits-all model. However, certain approaches have been empirically verified for use with a variety of clientele. It is critical that all counselors, especially those working with client populations that are oppressed, have both an overview of evidence-based practices and specific techniques related to these approaches in their clinical toolboxes to help them provide the best counseling services possible.

Counselors are frequently required to use evidence-based practices and need to know how to use them effectively in counseling clients who are oppressed. Specifically, the unique development of the therapeutic relationship between oppressed clients and privileged clinicians must be understood and addressed. Multicultural counseling experts Derald Wing Sue and David Sue maintain that the dynamics of oppression shift the influence of the therapeutic relationship. Thus, counselors must alter their application of evidence-based practice techniques.

Solution-focused brief therapy and low socioeconomic status

Take a moment to think about what the basic needs of your own life are. What is impossible for you to live without? For many of us, our basic needs are continually met. Therefore, they often go unnoticed — they are woven into our everyday lives and ways of being in the world.

For others, questions such as “Will I eat today?” or “Will I have a safe and warm place to sleep tonight?” are asked daily. Often, the answer is “no.” Concerns such as clean drinking water, access to hygiene products and finding adequate shelter affect an inordinate number of individuals in the United States. School counselors and licensed professional counselors have a moral and ethical obligation to address these matters, with the intention of removing barriers and cultivating a safe space for clients in both the therapeutic relationship and the environment beyond our office walls.

Glenda Johnson (one of the co-authors of this article) worked as a school counselor and an advocate in a school system in which the majority of students came from low socioeconomic status (SES) backgrounds. Many of the students were on free or reduced lunch plans because their families’ financial resources were severely limited. At the core of Johnson’s work was the intent to ensure that every child’s basic needs were met while they were at school. She emphasized the importance of working collaboratively with other school staff members to build a team and a foundation for connecting these students and their families to resources.

It is also vital to assess an individual’s behaviors, emotions and reactions through a holistic, biopsychosocial approach rather than focusing only on the school context. Learned behavior concerns, inattention, difficulty with emotion regulation (anger), sadness and loss of hope are often the result of a lack of resources. Johnson recalls that if a student acted out, one of her first questions would be, “Did you have breakfast this morning?”

Johnson shares an anecdote that highlights the powerful act of providing a safe, therapeutic space for students to identify and voice their emotions openly with peers. As a school counselor, she infused the identification of various emotions into a game of musical chairs, and what transpired was completely unexpected. A student identified a “sad” emotion and explained that their father recently had lost his job. The student was experiencing fear about not having enough food to eat during this time. Then, other students began to share similar stories without prompting. The game of musical chairs transformed into a collaborative and touching experience as the students identified common ground and connected on deeper levels of understanding and empathy.

When providing services to individuals from a low SES, counselors may find it helpful to use a strengths-based therapeutic approach. The evidence-based practice of solution-focused brief therapy (SFBT) zeros in on the therapeutic relationship and the clinician’s way of being. In this relationship, there is an acknowledgment of reality but also an emphasis on solution-focused thought and reframing. Focusing on strengths, the counselor and client work together to identify and move toward making small changes in any area because a small change in one area often leads to change in another area.

SFBT often introduces the “miracle” question: “Suppose that when you go to sleep tonight, a miracle occurs that solves your problem, but because you were sleeping, you did not realize what happened. When you wake up in the morning, how will you realize a miracle happened? What will you notice that you are doing differently?” These questions enhance and expose glimpses of solutions that an individual may struggle to identify in everyday life situations.

Additionally, SFBT places great value on successes. The counselor and client celebrate achievement and may use scaling to note the client’s progress. When working in a school system, the counselor could develop a creative and motivating way for children to rate themselves and their progress toward goals. For example, Johnson created a rating scale, complemented by the colors green, yellow and red, for kindergartners and first-graders. Green identified a completed goal, yellow identified progress toward a goal and red identified room for improvement. Similarly, she used a rating scale of 1-5 for students in second through fourth grades. Under this scenario, a student could check in with a rating, such as, “I am at a 3 and working toward a 5.” The counselor might respond, “What would it take to get to a 3.5?” The scale provided a visual for children to identify, track and celebrate their successes.

In SFBT, the counselor acknowledges client strengths and walks alongside these clients as they create and work toward their goals and future successes. “Flagging the minefield” is another technique counselors can introduce to help clients generalize and apply what they learn in counseling to future situations. Flagging the minefield is a particularly important facet of SFBT because it assists individuals in recognizing potential obstacles or barriers that will appear in their lives. The counselor and client work together to identify tools and resources the client can apply in other settings and relationships.

When working with students living in poverty, counselors should introduce a strengths-based approach and identify and gather resources to assist students and their families in removing barriers and meeting basic needs. Cultivating a safe, therapeutic relationship with students that focuses on solution building can assist them in building a stronger sense of self.

Motivational interviewing, SFBT and rural adolescent substance abusers

Adolescence is a vulnerable time and a critical period for developmental outcomes. During this stage of life, adolescents are exploring and forming their peer relationships and personal identities while beginning to distance themselves from family. Experimentation with substances often begins during this time. In 2012, Tara Carney and Bronwyn Myers found a correlation between the early onset of substance use and an elevated risk for later development of substance use disorders. Additionally, because early substance use may impact the growth of the adolescent brain, it has the potential to heighten one’s risk for delayed social and academic development.

Adolescents living in rural areas are marginalized in multiple ways. Children are an underserved minority population, as are rural populations. Sheryl Kataoka, Lilly Zhang and Kenneth Wells (2002) found that among youth with a recognized mental health need (estimated at 10 million to 15 million people), only 20-30 percent receive specialized mental health care. Rural communities are more likely to have fewer clinicians or require a long drive to see those clinicians, making it more difficult to obtain care. These disadvantages are exacerbated by the tumultuous nature of adolescence.

Motivational interviewing and brief interventions are two evidence-based practices particularly suited to this population because these approaches are generally influential in their therapeutic role while also being cost-effective. Motivational interviewing facilitates behavior change through exploration and resolution of ambivalence, and it focuses on being optimistic, hopeful and strengths-based. It uses principles of empathy, discrepancy, self-efficacy and resistance, and offers specific techniques such as OARS (Open questions, Affirmations, Reflective listening, Summarizing). SFBT emphasizes solutions, changes clients’ perceptions and behaviors, helps clients access their strengths and uses techniques such as exception to the problem, specification of goals and the miracle question.

Individual interventions with the use of the same interventions for multiple sessions are ideal, and research suggests that the earlier the intervention, the better the outcome. Early intervention shows better results than both preventive measures and later interventions because it reduces the need for more specialized interventions and provides applicable and useful tools and tactics for adolescents as they enter into various student, peer, familial and professional roles.

Challenges certainly exist when working with children and adolescents, particularly because many biological, environmental and social shifts occur organically during this time. As children and adolescents rapidly transition on a continuum of development, they become “moving targets.” Interventions that prove effective for those ages 11-12 often cease to be effective by ages 13 or 14. It is vital that counselors remain aware of this across the life span. Although adolescents are beginning to distance themselves from their caregivers, familial relationships and parental involvement remain crucial during this period.

To appropriately and competently involve the families of rural adolescents, some understanding of cultural values is necessary. In 2005, Susan Keefe and Susie Greene identified core Appalachian values, including egalitarianism, personalism, familism, a religious worldview, a strong sense of place and the avoidance of conflict. In the Appalachian region, assuming authority without demonstrating an authoritarian attitude is important. Language tends to be simple, direct, honest and straightforward. Family is extremely important, exemplified by the adage “blood is thicker than water.” Individuals’ relationship to the land is complex, and it can be beneficial to explore how clients view economic deprivation. In 2016, Sue and Sue also pinpointed some tendencies of rural clients, including having a “street-smart” attitude and way of being, depending on systems due to living in poverty and valuing survival at all costs.

As a result, subtle techniques such as stages of change, motivational interviewing and SFBT may be useful for this population. In stages of change, the intervention is matched to the stage of the client’s readiness to change (precontemplation, contemplation, preparation, action, maintenance, termination). Motivational interviewing facilitates an invitation to engage, and its strengths-based, hopeful tone can be helpful for clients living in an environment populated by deficits such as poverty and lack of education. The practical nature of brief therapy fits well with the no-nonsense worldview of clients coming from rural backgrounds.

Unfortunately, published rural studies often focus on specific regions or populations. Few interventions have been tested in rural settings, and the evidence from systematic reviews is often too general and not specific to the rural context. Ideally, rural communities could review interventions tested with various target populations in a range of settings. Such information is not usually available, however, and the strength of evidence is unlikely to be the only factor considered in choosing an intervention. The research on rural adolescent populations is limited, and little consistency exists across studies related to measurement tools. Furthermore, disseminating evidence-based practices to schools, families and community settings in rural areas is difficult due to the lack of resources.

However, it is important to note that there have been great improvements in substance abuse treatment and prevention with children and adolescents who live in rural areas. A 2016 Monitoring the Future survey of eighth-, 10th- and 12th-graders by the National Institute on Drug Abuse found the lowest ever reported rates of use for all illicit drugs, including alcohol, marijuana and nicotine. As further research is conducted, it will be important to delve into this information to identify what is already working with these individuals and what can be improved to better serve them moving forward.

Evidence-based practices with transgender clients

Transgender individuals face discrimination on multiple fronts. Many experience familial rejection, unequal treatment, harassment and physical violence during daily living. The rate of substance abuse within the transgender community is three times higher than that of the general population. There is a profound lack of competent health care for transgender individuals, and the care that is available may be inaccessible to a majority of the transgender population. The rate of unemployment within the transgender community is also three times greater than that of the general population, due in part to factors such as workplace discrimination, poverty and homelessness. Transgender people also face discrimination and mistreatment in shelters.

With high rates of homelessness, substance abuse and mistreatment, transgender people also have frequent interactions with law enforcement, where they can be subject to police brutality and discrimination. Within the criminal justice system, a high rate of physical and sexual assault is perpetrated against transgender individuals, and they are often denied medical treatment while incarcerated or detained.

Poor health outcomes for transgender people correlate with risk factors such as economic and housing instability, lower educational attainment, lack of family support and other intersectional factors such as race, ethnicity, immigration status and ability.

According to the 2015 U.S. Transgender Survey, 18 percent of transgender people who sought mental health services experienced a mental health professional attempt to stop them from being transgender. This correlated with higher rates of serious psychological distress and suicide attempts and an increased likelihood of running away from home, homelessness and engaging in sex work.

Research conducted in 2015 by Samantha Pflum et al. emphasized the lack of access to transgender-affirming resources and communities for individuals living in rural locations. The history of mistreatment and abuse of lesbian, gay, bisexual, transgender and gender-nonconforming clients by medical and mental health professionals must be acknowledged. Gender and sexual minority clients still face discrimination within the helping professions, and for individuals holding multiple marginalized identities, these experiences are compounded.

Even well-meaning providers are likely to make mistakes when working with marginalized clients. According to Lauren Mizock and Christine Lundquist, one of these mistakes is education burdening, or relying on the client to educate the provider about transgender culture or the general transgender experience. Resources exist to facilitate competence in these areas, and clinicians have a responsibility to refrain from placing the burden of their education on the client.

Some counselors participate in gender inflation, or focusing on the client’s gender to the exclusion of other important factors. Other counselors engage in gender narrowing, applying restrictive, preconceived ideas about gender to the client, or gender avoidance, which involves ignoring issues of gender altogether. Gender generalizing occurs when a clinician assumes that all transgender clients are similar. Gender repairing operates from a belief that a transgender identity is a problem to be “fixed.” Gender pathologizing involves viewing transgender identity as a mental illness or as the cause of the client’s issues. Finally, gatekeeping occurs when a provider controls client access to gender-affirming resources.

Acceptance of a client’s gender identity is ultimately not enough to provide competent, affirmative services. Understanding the nuances of these common mistakes will help clinicians provide a safe therapeutic environment that is affirming of these clients’ identity and humanity.

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, has developed competencies for counseling transgender clients (see counseling.org/knowledge-center/competencies) that focus on the following eight domains:

Human growth and development
Social and cultural foundations
Helping relationships
Group work
Professional orientation
Career and lifestyle development competencies
Appraisal
Research

Counselors can work within this framework to:

Promote resilience by using theoretical approaches grounded in resilience and wellness
Conceptualize the development of a transgender individual across the life span
Understand internal and external factors influencing identity development
Consider how identity interacts with systems of power and oppression (especially for minority transgender individuals)
Examine counselors’ own internalized beliefs and how those beliefs affect attitudes toward transgender clients
Reevaluate approaches to working with transgender clients as new research emerges

One intervention that has been identified for use with this population by Ashley Austin and Shelley Craig is transgender-affirmative cognitive behavior therapy (CBT). Transgender-affirmative CBT modifies CBT interventions to address specific minority stressors, such as victimization, harassment, violence, discrimination and microaggressions, that transgender people commonly face. This approach uses psychoeducation to help clients understand the connections between transphobic experiences and mental health issues such as stress, anxiety, depression, hopelessness and suicidality. Experiences are processed through a minority stress lens to help clients move from a pathologizing-of-self mindset to an affirming view of themselves as people coping with complex circumstances.

Clinicians are advised to affirm the existence of discrimination and to help these clients identify influences on their mental health by using the transgender discrimination inverted pyramid (see below).

Transgender individuals internalize messages at each level, and it can be beneficial to have a visual for how these messages trickle down and influence mental health. Clinicians can empower transgender clients by assisting them in challenging internal and societal transphobic barriers. A few examples are challenging negative self-beliefs, connecting with a supportive community and advocating for self and community.

Another approach recommended for use with transgender clients by Joseph Avera et al. in 2015 is the Indivisible Self model, an Adlerian wellness model refined by Jane Myers and Thomas Sweeney that emphasizes strengths. There are five wellness factors of self in this model:

Creative Self: Cognitions, emotions, humor and work
Coping Self: Stress management, self-worth, realistic beliefs and leisure
Social Self: Friends, family and love)
Essential Self: Spirituality, self-care, gender identity and cultural identity
Physical Self: Physical and nutritional wellness

This model easily can be adapted to a transgender-specific lens, especially regarding the Essential Self, by exploring gender and cultural identity and how they influence client experiences and beliefs. Used in conjunction with the ALGBTIC transgender competencies, the Indivisible Self model offers helping professionals both a conceptual and practical framework for working effectively with transgender clients.

For all clients, and transgender clients in particular, intersectional factors magnify the experience of oppression. Sand Chang and Anneliese Singh recommend addressing the intersectionality of race/ethnicity and gender identity for both clients and clinicians. This involves:

Challenging assumptions about the experiences of transgender and gender-nonconforming people of color
Building rapport and acknowledging differences within the therapeutic dyad
Assessing client strengths and resilience in navigating multiple oppressions
Providing a variety of resources that are affirming to transgender and gender-nonconforming people of color

In addition, assisting clients in locating social support is advised. Social support increases healthy coping mechanisms and helps with self-acceptance, thereby reducing psychological stress related to discrimination. Social support can also help to normalize and validate emotions related to discrimination.

Conclusion

Evidence-based practices have consistently been shown to be helpful to clients, but counselors must remember that they operate within the context of a relationship. To use evidence-based practices effectively, we must hold on to our humanness. The implementation of a single technique will look very different depending on who is in the room and what they are bringing with them.

Often, the expectations for using evidence-based practices might create pressure for counselors to follow a strict formula for treatment. Process variables such as honoring the personal relationship between the counselor and the client, maintaining a “therapist’s heart” and respecting the unique aspects of the client may seem to be at odds with the procedure for using a specific intervention. A working knowledge of multicultural issues can provide some context for how to shift evidence-based practices to fit the client rather than pressuring the client to conform to a prescribed, generalized format.

Using interventions with a solid evidence base is good practice. Adjusting their implementation on the basis of the unique identity of the person sitting across from us is great practice.

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

Geri Miller is a professor in the Department of Human Development and Psychological Counseling (clinical mental health counseling track) at Appalachian State University (ASU) in North Carolina. She is a licensed professional counselor, licensed psychologist, licensed clinical addictions specialist and substance abuse professional practice board certified clinical supervisor. She has been a volunteer counselor at a local health department since the early 1990s. Her clientele has primarily consisted of women with little opportunity for jobs or education and who experience barriers of poverty. Contact her at millerga@appstate.edu.

Glenda S. Johnson is an assistant professor in the Department of Human Development and Psychological Counseling (school counseling program) at ASU. She is a licensed professional counselor and a licensed school counselor in North Carolina. Her scholarly focus includes school counselors delivering comprehensive school counseling programs, students who are at risk of dropping out of high school and the mentoring of new counseling professionals.

Mx. Tuesday Feral received their master’s degree in clinical mental health counseling and a certificate in systematic multicultural counseling from ASU. They are the support programs director for Tranzmission, a nonprofit organization serving the Western North Carolina nonbinary and transgender community through education, advocacy and support services. Tuesday offers training and workshops in trans cultural competence and cultural humility on local, state and national levels.

William Luckett received his master’s degree in clinical mental health counseling from ASU with a certificate in addictions counseling. He has interests in somatic therapy approaches, mindfulness, religious and spiritual topics in counseling, and substance abuse counseling. He currently provides in-home counseling to rural families in Virginia.

Kelsey Fish is a student in ASU’s clinical mental health counseling program and a clinical intern with Daymark Recovery Services in rural Appalachia. Her clinical interests include expressive arts therapy, adolescents, and gender and sexual minority issues.

Madison Ericksen is a graduate of the clinical mental health counseling program at ASU. She has specialized training and interest in trauma-informed practices that use mindfulness, eco-based and expressive art therapies as complementary treatments alongside traditional therapy. She provides strengths-based and resiliency-focused outpatient counseling for children and families.

Letters to the editor: ct@counseling.org

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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.

Salutogenesis: Using clients’ strengths in the treatment of trauma

By Debra G. Hyatt-Burkhart and Eric W. Owens April 25, 2016

Mark was 16 when he found himself in a youth detention facility again. The reasons for his incarceration aren’t necessarily important; he had committed plenty of crimes in his life. His past actions came as no surprise. His father had been incarcerated for the entirety of Mark’s life. His mother was addicted to methamphetamines and often prostituted herself to pay for her addiction. Mark had been physically, emotionally and sexually abused throughout his life. He had also watched as his cousin was shot and killed.

Mark had been in and out of the Child Protective Services system since the age of 2 and the criminal justice system since he was 12. Mark was often defiant and oppositional when he was in placement or incarcerated. Yet again, Mark’s counselor was asking him why he kept fighting with staff and losing privileges. In a defiant, yet blunt, sad and hopeless way, Mark responded, “There’s nothing anyone can do to me in here that can hurt any worse than what people have done to me out there. They’ve got nothing on me.”

It’s easy to assume the worst from that statement. We can look at Mark’s history of trauma and conclude that he will likely never break the cycle. It’s also easy to assume that “out there” means society and “in here” means prison.

But what if we reframe Mark’s words? What if we step away from our assumptions about trauma and its effects and instead view Mark’s past as a gift of sorts? If Mark points to his chest when he says “there’s nothing anyone can do to me in here …” does this dramatically change our understanding? “In here” can just as easily mean within Mark as outside of him. After surviving everything that had happened to him out there, Mark could certainly survive in here too. Perhaps Mark could find strength from his past and learn from it.

The concept of posttraumatic growth is an important one. If we assume from what Mark said that his path is predetermined, then we are not very well-equipped to help him foster change. From the counselor’s perspective, if the belief is that Mark continually engages in self-defeating behaviors and doesn’t think things can ever change, all we see is resistance to the counseling process. We don’t see the attempts at self-preservation and the potential that Mark has; we see a defiant, angry, wounded young man who doesn’t want his life to be different. But if we look at Mark’s words and behaviors through a different lens, maybe we can help Mark see himself through that lens as well.

Pathology of the profession

Treating trauma has become an increasingly important aspect of the counseling field. Clinicians can quickly point to the symptomology in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and assign a diagnosis of acute stress disorder, posttraumatic stress disorder (PTSD) or reactive attachment disorder. Ongoing research has helped us to make major strides in explaining how the body reacts to trauma and how brain function changes after the experience of a traumatic event. Gone are the days of referring to someone as “shellshocked.”

Now we also recognize that trauma isn’t necessarily the result of a one-time, catastrophic event. Instead, trauma can be cumulative, and mental health professionals have even established labels such as Type I and Type II trauma to help clarify the distinction between catastrophic and ongoing exposures.

However, in a race to count symptoms and assign diagnoses, we may forget that trauma is best defined by the client’s experience. That is, if the client believes that he or she has experienced a traumatic event, then the reality is that the client has experienced a traumatic event.

A larger question may be, what has all of the attention on trauma done to the counseling profession? Rooted in a wellness model that focuses on holism, the profession of counseling attempts to set itself apart from its counterparts in psychology and psychiatry. The notion of professional counseling was, and hopefully still is, to focus on a client’s strengths as a pathway to mental health. Although understanding symptoms and diagnoses is increasingly important in the world of managed care, a diagnosis born of a set of symptoms does not necessarily drive the most effective treatment strategies.

Yet the focus on client strength has become less important in our daily work. When we conduct an intake for a client who has experienced a trauma, what do we look for? It’s common practice to focus on the client’s symptoms and daily struggles, but not as common to delve into the positives the client brings to therapy. The words we use and the questions we ask send critical messages to our clients, especially those whom we are meeting for the first time.

How many pages of most intake forms are devoted to pathology as opposed to strength? When we do ask about client strengths, too often it is not so that we may later return to those strengths in our work, but rather so that we can demonstrate to someone else that we completed the brief section of the intake form that asks about them.

When a client such as Mark tells us his story, too often we immediately make conclusions about his functioning and prognosis. In an effort to avoid “retraumatizing” a client, we may intentionally sidestep important client data. Does our concern about retraumatization translate to an assumption that the client is fragile and must be handled with sympathy or even pity? It seems counterintuitive to assume that Mark is fragile after everything he has survived.

None of this discussion is to imply that trauma isn’t serious and shouldn’t be treated as such. The experiences that our clients bring to therapy are often horrific, and there is simply no other word to describe them. The wellness perspective of professional counseling is rooted in the notion that we must respect the client’s experience and should meet clients where they are. What we are suggesting here is not a “you’re fine, it’s not a big deal” approach to treating trauma. Quite the contrary, appreciating the traumatic experience of the client and empathizing are characteristics critical to successful outcomes.

However, the very forces that have shifted our professional focus toward pathology and symptomology may very well assist us when it comes to moving back to our profession’s roots. Our goal is to move away from pathology and toward solution-focused, strength-based approaches to the treatment of trauma. These approaches not only benefit our clients by respecting autonomy and resilience, but they also benefit our profession by keeping us true to our historic roots.

Salutogenesis

As we attempt to reconcile the horrors of trauma with a model based in wellness, strength and holism, we are brought to the work of medical sociologist Aaron Antonovsky. Antonovsky defined health as more than a dichotomy of sick versus well. Instead, he argued that physical health exists on a continuum, and that wellness is more than simply the absence of illness or disease.

Antonovsky sought to discover why people who are exposed to the same stressors may have very different outcomes related to physical health. Although stress is ubiquitous, Antonovsky noticed that disease is not, and he sought answers as to why that is. In the process, Antonovsky developed the term salutogenesis, which comes from the Latin salus, meaning health, and the Greek genesis, meaning origin.

If salutogenesis is the origin of health, what does this term mean for professional counselors? Simply put, as counselors, it is important for us to examine what it means to be mentally and emotionally healthy. It means that mental health is not merely the absence of mental illness, as defined by the deficient symptomology described in the DSM-5, or, worse, being defined as subsymptomatic due to having an inadequate number or severity of symptoms. Instead, salutogenesis in counseling suggests that mental health exists on a continuum between asymptomatic and diagnosable mental illness. Salutogenesis suggests that mental health is more than simply lacking a diagnosis. Instead, mental health incorporates a holistic vision of the self. It is, in fact, the essence of the counseling profession.

Furthermore, salutogenesis captures the notion that many people may be exposed to the same stressor yet experience different outcomes. Again, stress is ubiquitous, but mental illness is not. Three passengers may be riding in a car that is involved in a severe accident. All three passengers experience the same accident and may have similar physical injuries yet still experience vastly different psychological results. One passenger may experience acute PTSD, whereas another might simply have a nervous reaction when hearing the squeal of tires. The third may become a race car driver without so much as a second thought concerning the accident.

Salutogenesis examines the factors that individuals possess that help them overcome stressors such as traumatic exposures. Furthermore, salutogenesis examines why one person may define an experience as traumatic while another person does not. In this, Antonovsky’s work intersects with that of Urie Bronfenbrenner, who discussed risk and protective factors. Risk factors are those that may disrupt one’s developmental processes; protective factors are those that mitigate risks.

Bronfenbrenner described human development as a process inexorably tied to the influences of the systems in which a person functions. He described far-reaching influences, such as world politics and societal norms, and influences that are close to home, such as family dynamics and peer relationships. Because every person has a different set of systems, every person experiences the interaction between himself or herself and his or her environment in a different way. It is these differences that create our individual perceptions of events and our unique sets of risk and protective factors. As counselor clinicians, the questions become how we can use these unique experiences and characteristics to promote wellness, and how we can help our clients return to wellness should they experience a traumatic event.

A shift toward strength and growth

Antonovsky examined wellness through the notion of “sense of coherence,” which is a construct that helps us connect mental wellness to systemic influences, risk and protective factors, and individuals’ perceptions. Sense of coherence is really about meaning making. It is about the degree to which people believe they have what it takes to understand the world around them (comprehensibility) and possess the resources and skills to meet the challenges of that world (manageability), and that these challenges are worthy of the efforts to surmount them (meaning). When these three factors align from a position of strength, mental wellness is likely.

Let’s return to our example of the three individuals in the car accident. Each person experienced this event in his or her own way, and each made sense of it in a unique manner. Perhaps the person with acute PTSD was unable to manage the stress presented by his injuries or the emotionality of the accident. Maybe another passenger ruminated on concerns that such an accident could happen again and worried that she wouldn’t be able to handle it happening again.

There are no clear answers, but what is evident is that the passengers who experienced ongoing stress reactions were not able to make sense of the event or find the resources within to meet the significant challenges of the experience. These passengers experienced a diminished sense of coherence. But one of the great things about human beings is that we are continually experiencing growth and change. The circumstance of a lack of diminished sense of coherence isn’t necessarily permanent.

As we look at our work with people who have experienced trauma, like the people in the car accident, we can use a focus on sense of coherence to promote a return to wellness. Helping clients gain an understanding of their experiences and assisting them in finding their inherent strengths shifts our work as counselors into a salutogenic approach. We can validate the trauma while putting the experience in a context that allows clients to see their own potential. We can nudge them toward creating an inner narrative that places them in a position of strength and power over their experience. We can focus on changing the “why me?” to “why not me?” We can help clients look at the protective factors and unique strengths they possess that have helped them survive thus far. Because on whatever level, if they are in your office, they have been surviving. When clients can find those strengths, we can help them move beyond surviving to thriving.

Humans are resilient by nature. When we look at the statistics regarding how many of us will experience a traumatic event, the numbers are pretty grim. Using a broad definition of trauma — one that validates that trauma is in the eye of the beholder — nearly all of us are likely to have some traumatic exposure. Yet those who suffer from acute stress reactions as a result of such exposure are generally believed to be less than 20 percent. In other words, recovery and resilience are normative. In fact, a growing body of work is focused on the experience of growth after and as a result of traumatic experiences.

In their work, Richard Tedeschi and Lawrence Calhoun have been exploring the ways in which people grow from negative experiences. We are all likely familiar with someone who has grown from a negative event. Maybe a loved one survived a potentially terminal illness that created in them a mentality of “life is short; carpe diem!” Perhaps an accident promoted awareness that life is fragile and that the most important things are relationships with loved ones.

Tedeschi and Calhoun identified five domains in which such posttraumatic growth is likely to occur:

1) Changes in the perception of the importance of relationships

2) Increases in spirituality

3) An increased sense of self and personal strength

4) A broadening of the sense of possibilities for one’s life

5) Increased appreciation for life

As we look at meaning making, sense of coherence and systemic interactions, it makes sense that these areas would emerge. If we can approach our clients from a salutogenic perspective, we may even be able to promote such growth.

Putting it into practice

So, what does all of this look like when we are working with clients? Again, this should not be confused with a Pollyanna view that everything is great. It is not a dismissal of the negative symptomology or the suffering that a client may be experiencing. Instead it is the process of leaning in to find the client’s strengths that are present even in the midst of despair.

The thing is, clients may not have the slightest inkling that they have any strength left. They may believe that this experience has taken everything from them. It is our job as counselors to find even the tiniest spark of ability and fan that flame until it burns bright enough for them to see it. We explore from a strength-based approach. We ask strength-based questions such as “What was working before? What is going well? What resources do you have? What if a miracle happened? What gives you meaning?” Clients may not have answers in that moment, but we can help them to find answers.

We personally love the question, “What do you ‘groove’ on?” We ask clients what is present in their lives that makes them smile, gives them a lift and helps them find peace, even if those things come in the smallest of measures. We can use that information to connect clients to other strengths upon which they can build, much like stacking blocks. We can promote a feeling in our clients that they are the experts on themselves, and they can help us to promote their positive change. We can empower our clients to believe that they are capable of coping. We can help them draw on both their inner reserves and the external resources that they might be having difficulty accessing.

We aren’t suggesting that a salutogenic approach is easy, nor is it a panacea for all people in all circumstances. As professionals, we know that we must meet our clients where they are. Validation of a client’s experience and careful interventions are always important. Some clients may have a hard time identifying any strengths. They may be so wounded that it would make such an approach a hard sell. What we must do as clinicians is be patient, empathize and continue to provide strength-focused reframes whenever possible. This dance requires sensitivity on the part of practitioners. With a focus on clients’ current needs and an eye toward positive coping, we can help our clients to move forward in their journeys.

We would be remiss if we didn’t discuss the fact that we share the journeys of our clients in very real ways. Any clinician who has worked with these issues has been warned of the dangers of vicarious trauma — the potential that, as clinicians, we can experience disturbance as a result of just listening to the experiences of our clients. The result of such exposure can be as mild as thinking too much about a client or as severe as full-blown PTSD symptoms.

But there is an upside. If we can be disturbed by our clients’ disturbance, then we can also grow from watching our clients grow. Vicarious posttraumatic growth is a burgeoning area of study that suggests we can experience the same kind of fundamental shifts in positive thinking that our clients may undergo just by watching them do it. What a great side effect of a salutogenic approach to our work.

It seems that every day there are terrible, traumatic things reported in the news. There are mass shootings, natural disasters, horrific accidents and incidents of community violence. It seems that each day creates a new Mark. If we were to focus on the pathology of Mark’s experience and the bad in the world, he — and we — may never choose to venture out again.

Mark didn’t choose that path, however. He eventually chose to be a phoenix. He decided to rise up from the ashes of his own experience. It wasn’t an easy process. A great deal of emotional pain was involved. He had to let go of a significant amount of anger and blame. He had to come to understand that all of his experiences, all of his suffering, all of his trauma, did not define him. Mark came to know that all of those things made him tough. They made him compassionate toward others. They made him a survivor who had the skills to fly as high as he wanted to go. Mark chose flight. Watching him fly was beautiful.

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

Debra G. Hyatt-Burkhart is an assistant professor in the counselor education program at Duquesne University in Pittsburgh. With more than 25 years as a practicing clinician, her work focuses on positive approaches to clinical supervision and treating trauma. Contact her at hyattburkhartd@duq.edu.

Eric W. Owens is an assistant professor and graduate program coordinator at West Chester University of Pennsylvania. He has worked in higher education, K-12 and clinical settings for 20 years. His work focuses on strength-based approaches to trauma treatment and crisis intervention. Contact him at eowens@wcupa.edu.

Letters to the editor: ct@counseling.org