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Counseling Connoisseur: Thanatechnology – Grief and loss in a digital world

By Cheryl Fisher June 8, 2018

Thanatechnology: Any kind of technology that can be used to deal with death, dying, grief, loss and illness.


Kelly (an alias), an eighth-grader, sits with her friends in the school auditorium as her principal calls out the names of each of her classmates who were killed in the recent shooting. To honor the lives of these young people, the school is hosting a remembrance ceremony. As tears run down her face, Kelly huddles close to her schoolmates and clicks away on her phone posting messages on several social network sites and a memorial site that she and her friends created. A text message pops up from a boy she met on one of the sites. He is a survivor of a school shooting that happened a couple of years ago — he understands.

Tony’s (alias) phone vibrates, rousing him from his slumber. He looks at the clock – it’s 2 a.m. He has to be up for school in just a few hours. He squints, trying to read the alert on his phone. Another teenager has died from drug overdose. He heaves a mournful sigh and turns on the bedside lamp. His phone begins to blow up with social media posts. The deceased didn’t attend his school but is related to his girlfriend’s best friend. Tony attempts to return to sleep, but he keeps thinking about the teenager [and] wondering why it happened.

Without a doubt, the youth of today are often exposed to significant and traumatic losses. Traditionally, we have marked death with rituals such as funerals and memorials and grieved with the support of counseling, faith communities and neighbors. In more recent years, technology has provided additional ways to remember and mourn, such as creating online memorials, seeking distant or virtual grief counseling and connecting with family, friends and even strangers without geographical limitations. It erases time and distance and allows for virtual experiences and expressions that promote a narrative that lives forever.

Digital Presence and Youth

In Dying, Death, and Grief in an Online Universe, researchers Kathleen R. Gilbert and Michael Massimi observe that digital technology can “bring people together for social support, provide information, and offer a venue for conducting grief work such as telling stories or building digital memorials.”

In another section of the book, researcher Carla Sofka writes that young people are even more likely to seek grief support online. Sofka explains that the internet, social media and other digital platforms are where younger generations are most comfortable because they provide opportunities for social interaction; a sense of independence and privacy; the ability to express and form their own identity; a sense of community that includes those that are marginalized; and instant alerts and communication. All of these elements allow youth to seek and find like-minded communities that can provide immediate support and strategies for coping with myriad life issues — including death and dying, and grief and loss.


Social Interaction

Online bereavement forums and chat rooms provide a sense of social connection with users. Sites such as Caring Bridge allow multiple users to maintain a virtual journal offering information and capturing narratives that are accessible to members. Tumblr, Facebook and Instagram create spaces where youth can just “hang out.” Video calling technology such as FaceTime and Skype bridge the distance between users and promote interaction and communication. Additionally, grief counseling may be offered via video, phone, chat or email formats.

Independence and Sense of Privacy

Teens turn to technology to carve out a private space for self-expression. However, research indicates that internet use often provides the illusion of anonymity, which may encourage a false sense of privacy. The struggle for privacy is nothing new: The tension between privacy and personal expression has existed between teens and parents for decades. In It’s Complicated: The Social Lives of Networked Teens, danah boyd*, principal researcher at Microsoft Research notes that social media introduced a new dimension to this age-old power struggle. Instead of worrying about what teens wear outside, parents are concerned about what pictures teens are posting about what they wear outside.

[*boyd prefers to spell her name with lowercase letters.]

“Although teens grapple with managing their identity and navigating youth-centric communities while simultaneously maintaining spaces for intimacy, they do so under the spotlight of a media ecosystem designed to publicize every teen fad, moral panic, and new hyped technology,” writes boyd.

Yet, online spaces allow for exploration of feelings and thoughts, examination of death anxiety, and expression of grief and loss. For example, a 14 year- old client crafted an entire mix of music and prose around the complicated emotions she experienced related to the death of her estranged father who had abused her as a little girl. Using an alias, she posted the eulogy online and watched as strangers connected with her, validating her feelings and experience.

Expression and Influence of Identity Formation

The internet provides creative space for expressing grief and honoring loved ones. Sites such as KIDSAID.com, offer children the opportunity to connect, interact and creatively express their grief. In addition to expressive sites and online memorial services such as Legacy, Remembered.com and Your Tribute provide an unfettered opportunity to honor loss, especially for those who are marginalized or disenfranchised. The use of letters, photos and sound provide rich and detailed memorials that allow users to express their grief, absorb their loss and ultimately move forward.

Sense of Community

Blogs provide a venue to capture experiences and to cultivate topic-based virtual communities. Boyd suggests that these constructed networks serve as a public place to interact with real and imagined communities, thus satisfying a desire to be part of a broader world.

Instant Alerts

Online communication is often in real time. Twitter, Snapchat and a variety of other digital sites offer instant notifications and ongoing engagement. Technology allows users to gather multiple streams of almost instantaneous information from afar. For example, recently I was at a social gathering where a young woman, glued to her phone, was continuously texting. At one point I interjected, “Is everything alright?” She looked up and shook her head. “No, I have a friend who was just in a car accident and the medics are transporting her to shock trauma. Her parents are on their way to the hospital — but no one thinks she’s going to make it.”

The accident occurred in another state, yet this young woman was experiencing the event minute by minute via her phone messaging.

There are numerous attractive features to thanatechnology. Information is persistent and endures. There is a sense of immortality and legacy when a person’s comments, photos and work is posted in cyberspace. It is visible to infinite numbers of individuals. It is spreadable, and with one repost or share, hundreds more are invited into our experience. It is searchable. Just yesterday someone emailed me after reading my article on pet loss and grief. She had been Googling information about pet loss and my article popped up. I was able to provide her with additional support resources.

While there are many helpful aspects of using technology for grief support, there are some serious causes for pause. Are the online interactions healthy? Who is actually participating in the network communities? Are youth oversharing personal information while in a vulnerable state? How pervasive are social divisions and are they perpetuated in the participating forums?

Clinicians, parents and educators must be digitally literate and provide opportunities for genuine face to face connection while acknowledging the cyberworld of teens. Using technology during this very vulnerable time can provide tremendous support and healing, but it may pose risks. Counselors have the responsibility to help youth develop the skills to navigate technology in a way that creates a safe environment for their grief experience and promotes bereavement support.





Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy: and geek therapy. She may be contacted at cyfisherphd@gmail.com.






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.

Canine companions

By Laurie Meyers May 4, 2018

Having kids and young adults train rescue dogs isn’t technically animal assisted therapy, but for the kids—and dogs—involved in the Teacher’s Pet program, the result has definitely been therapeutic.

The youth —with the help of professional animal trainers— use positive reward-based training to increase local rescue dogs’ chances of being adopted. In return, working with the dogs helps the students develop patience, empathy, perseverance and hope, says Amy Johnson, the creator and executive director of Teacher’s Pet, a Detroit-area non-profit program.

The idea for the program was born when Johnson, a former public school teacher, was working as a dog training instructor at the Michigan Humane Society. Johnson, an American Counseling Association member, wasn’t sure what the training would look like at first — she simply knew

Images courtesy of Teacher’s Pet. Identifying features of (human) participants have been blurred for confidentiality.

she wanted an intervention that would help both kids and dogs. Johnson contacted every group she could find in the United States and Canada that worked with both youth and dogs to learn more about how their programs worked. Her intent was to work with kids who — like their canine counterparts — were behaviorally challenged and often unwanted. So, not only did Johnson contact school counselors and psychologists for their input, she decided to become a professional counselor herself.

The end result was a program that is 10 weeks long and meets twice a week for two hours. Teacher’s Pet currently works with teens from an alternative high school and three detention facilities and young adults, aged 18-24 at a homeless shelter, says Johnson, a licensed professional counselor. At each facility (except for the homeless shelter), the training takes place on site. Participants from the homeless shelter are brought to an animal shelter to complete the program.

The program’s group facilitators are all professional trainers and they choose only dogs with good temperaments to participate, says Johnson, who is also the special projects coordinator and director of the online animal assisted therapy certificate program at Oakland University in southeast Michigan. Before the participants begin working with the dogs, the facilitators give them some safety training.

“We spend the first day going over body language and stress signals,” Johnson says. “They meet the dogs on day two, after one more hour of dog body language education.”

Other safety measures include limiting the number of dogs — five or six per class of 10 students — and keeping the dogs on long tethers placed 10 feet apart so that they can’t interact with each other, she says. There are also always at least four trainers in the room and the dogs are closely monitored. If a dog gets overexcited, is struggling to get off the tether or barking at another dog, a trainer will remove it from the room, Johnson says.

At the beginning of each session, the lead facilitator goes over the goals for the session, such as teaching the commands “sit,” “stay” or “down,” learning to walk on a leash or not jump for the food bowl. The individual trainers explain how to teach the commands and let the teens or young adults do the actual training as they supervise. The dogs are never forced to participate—if an individual dog is nervous or reluctant, the goal for the day is to establish trust and confidence, she says.

Johnson says that sometimes dogs that come off the streets have specific problems like trembling when people walk by. In that case, the students will sit with the dog until it becomes more comfortable and then start with small steps like going for a brief walk outside.

As participants are teaching the dogs new behavior, often their own behavior changes, she says.

In particular, a lot of the teens and young adults who participate have poor communication skills, Johnson says. For instance, some are so shy that they don’t project their voices and the dogs don’t respond to their commands. The participants have to learn to speak firmly and assertively, and to demonstrate a sense of command by standing up straight. One boy told Johnson that he decided to test the tone of voice and body language he used with the dogs on his peers to see what would happen. Imitating the behavior he used with the dogs gave the boy more confidence and he found it easier to interact with his peers, she says.

Johnson describes another boy who was very angry, had little patience and low impulse control. He had a soft heart and would choose dogs that were struggling, which told Johnson that he was projecting his anger.

“Inside he was like the dogs [scared],” she says. So the trainers paired the boy with a dog that was afraid of men. His job was to make the dog like him, Johnson explains. The boy had to be patient and sit with the dog. As the dog got calmer and more confident, the boy would gently encourage it to move closer and closer. By the end of the program, the dog was joyfully playing with boy.

Johnson says that the program facilitators coordinate with the participants’ counselors when possible, so that if they are struggling with particular problems — such as patience or impulse control — training sessions can include activities that help address those difficulties.

The teens and young adults also learn from each other. The first hour of each session is devoted to training and the second to journaling and “debriefing” — talking as a group about what worked and what didn’t.

Johnson believes that even just the oxytocin release that comes from spending time with the dogs is highly beneficial. The program participants are often deprived of loving human touch and the dogs will lick and hug and make them laugh — reducing their anger and anxiety.

As the program draws to end, saying goodbye isn’t easy, but that in itself can be a lesson learned, Johnson says. The students start to detach from the dogs a little bit, and they’ll talk about how that is a normal part of processing grief and loss, she says. The kids also write letters to potential adopters  touting the dogs’ accomplishments.

When the program is over, the teens and young adults say goodbye to the dogs and learn that they can say goodbye and not have it be the end of the world, says Johnson. The participants also get lots of pictures of themselves with the dogs and a certificate for the wall. Many former students have told Johnson that they keep a picture of themselves and the dog they trained on their dressers.

“I had a youth email me seven years later and ask me for another copy of his certificate because his was in a storage unit that was auctioned off,” she says.

Many graduates want to volunteer with Teacher’s Pet for adoption and other events, Johnson says. The organization also remains a resource for the students — they can get letters of recommendation or basic things like clothes for school or school supplies if needed.

Johnson says that Teacher’s Pet is also currently working with the American Society for the Prevention of Cruelty to Animals (ASPCA) on a longitudinal study to determine if the program produces behavioral changes in the kids, and if so, for how long.




For more information about Teacher’s Pet, visit the website at teacherspetmi.org or email Amy Johnson at amy.johnson@teacherspetmi.org.

Related reading, on therapeutic power of the human-animal bond, from the Counseling Today archives: “The people whisperers




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor:ct@counseling.org




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.


’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.