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Assessment

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.

Case conceptualization: Key to highly effective counseling

By Jon Sperry and Len Sperry December 7, 2020

In their first session, the counseling intern learned that Jane’s son had been diagnosed with brain cancer. The therapist then elicited the client’s thoughts and feelings about her son’s diagnosis. Jane expressed feelings of guilt and the thought that if she had done more about the early symptoms, this never would have happened to her son. Hearing this guilt producing thought, the intern spent much of the remaining session disputing it. As the session ended, the client was more despondent. 

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.

Presentation

Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.

Predisposition

Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.

Precipitants

Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.

Perpetuants

Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change. 

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids closeness to avoid perceived harm

Predisposition:

  • Biological: Paternal history of anxiety
  • Psychological: Views herself as inadequate and others as critical; deficits in assertiveness skills, self-soothing skills and relational skills
  • Social: Few friends, a history of social anxiety, and parents who were highly successful and critical
  • Cultural: No acculturative stress or cultural stressors but from upper-middle-class socioeconomic status, so from privileged background — access to services and resources

Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has
access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation). A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant). She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern). Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants).

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors).

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological); she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological); she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social). Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural).

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment).

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis).

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Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

 

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For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence.

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Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at jsperry@lynn.edu or visit his website at drjonsperry.com.

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at lsperry@fau.edu.

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

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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 need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

“I am afraid I might actually do it,” the 31-year-old woman told me. Abigail (not her real name) was referring to ending her own life. For years she had struggled with depression, and she teetered on the brink of suicide. Medication had helped her only minimally. Her ideation was unquestioned and her plan was clear.

These were frightening words to me, and for weeks I held my breath, fearing a phone call from her husband announcing that Abigail had completed suicide. A brief hospitalization had somewhat stabilized Abigail’s life, but she was worn out. Upon her release from the hospital, her husband and I worked together to form a safety plan in an attempt to ensure that he wouldn’t be left a widower and her two children left motherless.

I have seen many clients like Abigail over the span of my career as a licensed professional counselor. Managing clients who are suicidal is a common occurrence in therapy. Data are scarce regarding the percentage of suicidal clients a clinician in general practice might have. However, most of the numbers indicate that up to half of an average client caseload is on the worrisome side of the suicide risk continuum. That percentage is far greater, of course, among clinicians who work with specific populations or disorders that have been shown to have increased risk for suicide. Abigail fell into one of these high-risk categories. Yet as recently as 2006, a meta-analysis by Stefania Aegisdottir and colleagues published in The Counseling Psychologist basically indicated that clinicians aren’t very good at assessing risk. That is frightening.

Equally disturbing is research showing that about one-quarter of us will experience the loss of a client to suicide during our careers, but many (if not most) of us are poorly prepared to manage suicide risk. In a 2013 study by Cheryl Sawyer and colleagues of 34 master’s-level counseling students, 15% reported no confidence at all and 38% reported little confidence in their ability to assess for suicide risk, whereas only 3% reported feeling fully competent to manage suicide risk.

But the problem isn’t just with graduate counseling students. In spring 2017, I presented a workshop for my state professional counseling association’s annual conference. The workshop focused on assessing risk of harm to self or others. I asked the 85 or so participants if they regularly worked with clients who were suicidal. Every hand went up. I then asked if they felt that their training had adequately prepared them for assessing suicide risk. Only two people in the entire group indicated that they felt prepared.

This response is consistent with an article titled “Psychologists need more training in suicide risk assessment” that appeared in the April 2014 Monitor on Psychology. The article, which detailed a task force report and summit organized by the American Association of Suicidology (AAS), said in part, “After three years of study, the AAS task force … called for accrediting organizations, state licensing boards, and new state and federal legislation to require suicide-specific training for mental health professionals.” The article went on to say that “many psychology graduate students are trained only on suicide statistics and risk factors, not in clinical methods of conducting meaningful suicide risk assessments.”

Something is amiss. Not only does it appear that mental health professionals receive inadequate training in this area, but some researchers even question whether the little training we do get has any efficacy. Robert Cramer and colleagues, writing in 2013 about suicide risk assessment training for psychology doctoral programs, stated that “no existing training methods have been investigated specifically in traditional clinical or counseling psychology training settings and samples.”

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders addresses suicide risks by diagnosis, it does not provide any risk assessment tools for clinicians. Given the picture I’ve painted, how can it be that in 2020, we do not have any clear standard — often referred to as best practices — for suicide risk assessment?

Looking back

To identify what blind spots the counseling profession might have, I try to imagine what people will say about our field 50 or 100 years from now. After all, it is easy to look at the past and recognize our errors and oversights. As developmental psychologist Jerome Kagan wrote in Three Seductive Ideas (2000), “If you had lived in Europe as the fifteenth century came to a close, you would have believed that witches cause disease … and that pursuit of sexual pleasure depletes a man’s vital energy and guarantees exclusion from heaven.”

These ideas sound ridiculous today. If you are younger than 30, the following facts from the more recent past will sound equally ridiculous to you:

  • If you were a mental health person in the 1930s, “moron” and “idiot” were formal classifications of what we now call developmental delay. In addition, you believed ice water baths and jumping on a person’s chest could cure schizophrenia.
  • If you were practicing in the 1950s, common treatments for depression included prefrontal lobectomies. Some physicians literally lined patients up and performed these barbaric procedures in 10-15 minutes each.
  • If you were practicing therapy in 1970, you believed that homosexuality was a mental illness. Just a few years ago, some people believed in and actually practiced praying homosexuality out of a person (one of the milder techniques used in so-called “conversion” therapy).
  • In the early 1980s, hardly anyone had heard of AIDS, stalking, Munchausen syndrome by proxy, or autism.
  • When I was in graduate school in the mid-1980s, none of my master’s or doctoral professors even mentioned what we now call “evidence-based” therapies. Cognitive behavior therapy was leading the way, but most of us described ourselves as “eclectic,” and after our supervision hours were satisfied, we all basically did whatever we thought worked.

The lack of exactitude in the mental health field doesn’t end there. When I was a regular lecturer at the FBI Academy in the 1990s, I began receiving calls from around the country about various applications of counseling to law enforcement. One call came from a sheriff’s department. Five officers had been involved in a shooting, and departmental procedure required a fitness-for-duty assessment. The sheriff was asking me to do the assessments, so I began researching this facet of risk assessment and discovered there was no standard whatsoever in the field regarding fitness for duty. It was simply a judgment call on the part of the clinician. Hard to believe, isn’t it?

Apparently, we have a lot to learn. I’m hoping that in the not-too-distant future, therapists will be saying, “Remember back when there was no standard for suicide risk assessment? Unbelievable!”

Risk assessment tools

It would be easy to confuse lack of a standard with lack of tools. We have lots of tools. Among the assessment tools commonly used are the Beck Scale for Suicide Ideation, the Reasons for Living Inventory, the Suicide Probability Scale, the Suicide Intent Scale  and the SAD PERSONS scale, to name just a few. However, there is very little, if any, data clearly demonstrating that one tool is better than another or that assessment tools have any efficacy at all.

One exception is the Beck Scale for Suicide Ideation, which is as well-researched and as validated as any instrument available. But there is still no assumption that clinicians use “evidence-based” assessments. Does that sound a little crazy to anyone but me?

In a 2016 article in the Journal of Psychopathology and Behavioral Assessment, Keith Harris, Owen Lello and Christopher Willcox identified a number of issues with the standard practice of suicide risk assessment, but again, there is no consensus in the field. The authors noted that “an American Association of Suicidology task force … and other experts have called for improved teaching guidelines on valid risk assessment. The findings of this and related studies bring to light weaknesses in current suicide risk assessment and conceptualization, and concerns that some clinical educators and practitioners may be unaware of the limitations of popular tests. There is a clear and present need for updating core competencies for accurate assessment and risk formulation.”

How do we know our assessments are effective?

I’ve never lost a client to suicide, and it would be tempting to suppose that this indicates my system of suicide risk assessment and intervention is effective. However, there are multiple factors unrelated to my competence that might lead to the same outcome. For instance, clients who come to counseling might simply be more motivated to live than those individuals who don’t come to counseling. In such cases, perhaps any adequate therapist would have been effective.

There may be other factors in my clinical work that are the cause of my fortunate success. In other words, perhaps I have been doing something else that works (maybe good rapport or social support), but I’m not aware that this is what is actually helping as opposed to my suicide assessment and intervention. And, of course, I could have been wrong in assuming risk at all. These potential false positives could mean that my clients didn’t kill themselves because they weren’t really suicidal to begin with. And these are just three possibilities.

This is why we need research and standardization. Standardization adheres to accepted research format. My students often start comments and questions with “I think …” or “I feel …” I never let that slide. I don’t care what we think or feel. What do we know? That is what research — evidence-based practice — helps us answer.

I understand that my words may be hard to hear. Before evidence-based therapies became the ethical standard, all of us in mental health were doing what we thought worked. Any challenge to our practice was met with a defensive posture, and I was among the clinicians taking that stance. We felt or believed (just like my students) that our methods worked because our clients appeared to get better. We were certain we were right, and maybe we were, but we had nothing concrete on which to base our assumptions. That seems obvious in hindsight, but the thought was new to us at the time.

Some of our clients might have seemed better but really weren’t. Their desire for improvement might have masked symptoms, and we also know that clients want to please us. They might easily have presented their cases in a brighter light than they should have. Other times, they might have been better temporarily but regressed after terminating therapy. We can easily misinterpret our positive feelings about our work as evidence that it is effective. Could we be making similar mistakes right now in risk assessment for suicide?

A perfect case in point is no-harm contracts. One of the things that clinicians seem to agree upon widely is that there are benefits to using no-harm contracts — also called safety contracts — with our clients who are suicidal. Yet years of attempts to validate the efficacy of no-harm contracts have turned up nothing. M. David Rudd, Michael Mandrusiak and Thomas Joiner Jr. noted in a 2006 article in the Journal of Clinical Psychology: In Session that “no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness.” A 2005 article by Jeane Lee and Mary Lynne Bartlett reported the same thing. In other words, the one thing that almost all of us do has no data supporting its efficacy.

What we risk

When I’m working through clinical issues, I find it helpful to think of what I would say if I were sitting in front of the ethics committee of my licensing board or if I were being scrutinized in court by a hostile attorney. How hard would it be for an attorney to find 10 clinicians who would propose that I made the wrong decision? If all you can say is, “I thought this was a good idea,” then you have a very weak defense.

In such cases, we risk losing a lawsuit and perhaps having our licenses censured, suspended or revoked. The more important risk, however, is that we might fail our clients and they might lose their lives when we could have served them better.

A standard approach

I’m not the first person to notice this problem, of course. AAS, among other groups, regularly focuses on the development of reliable and valid processes for assessing suicide risk, but as of yet, the solutions are elusive. A number of research studies have attempted to address the issue. James Christopher Fowler summarized well in a 2012 article in Psychotherapy when he wrote, “We are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions.” This summary brings us right back to where we started.

Combing through the research over the years, I’ve narrowed what we know about risk into a three-factor risk model and five components of risk in my assessment process as a starting place for evaluating the efficacy of risk assessment. I’m not supposing that my work is original or that my system is better than another. I’m only proposing that what I present here is consistent with what we know and that it can serve as a starting point for collecting evidence and producing a standard of best practice.

Three-factor model: The three-factor model proposes that clients are at risk or protected from risk in three global arenas: presenting factors, personal factors and protective factors.

Presenting factors include diagnoses (depression, for example), loneliness, divorce, prior attempts, suicidal ideation and other situational factors that put clients at higher risk for suicide. 

Personal factors include pessimism, weak problem-solving skills and minimal coping skills that put clients at higher risk for suicide. Included here are actuarial data. Some populations, such as female African Americans, have been shown to have very low risk for suicide, whereas others are statistically very high (e.g., Native Americans, male Caucasian teens, the elderly).

Finally, protective factors counterbalance presenting and personal factors. This would include healthy relationships, strong social support networks and religious commitment.

Moffatt’s HM4: The model for assessing risk that I use addresses all three factors. My HM4 model has five components of examination — hopefulness, method, means, motivation and mitigating circumstances.

The research is clear. People without hope are at high risk. Sometimes this is called “future orientation.” Regardless, the question is, “What does my client have to look forward to tomorrow, next week or next year?” If the answer is “nothing,” then I’m worried.

Method refers to one’s plan. The more specific and clear the method, the more I’m concerned. “I sometimes think the world would be better if I just didn’t wake up” is a vague plan. “I have been collecting my mother’s medications a little at a time. I have them hidden in my room, and I plan to take them all at once when everyone leaves for work and school” is a very precise plan.

Means has to do with the tools to be used and the ability to carry out one’s method of dying by suicide. One of the children in my practice once said he wanted to kill himself. His method was to invent a robot that would kill him in his sleep. His method was clear, but the means of executing that plan were completely unrealistic. Even if he could have invented such a robot, the likelihood that he would be able to carry out this plan without attracting his parents’ attention was minimal. On the other hand, teens and adults often have much more realistic means and, because of freedom of movement and access to weapons, drugs and other resources, are much more likely to succeed in a suicide attempt.

Motivation refers to the level of desire to follow through and complete suicide. Fortunately for us as counselors, most of our clients don’t want to die. Their motivation is low even though their emotional pain is high. This is why suicide hotlines work. People are so highly motivated to find a solution (having low motivation to complete the act of suicide) that they will call a complete stranger to seek help. 

Finally, mitigating circumstances are issues that are so weighty that they override the other areas of assessment. Mitigating circumstances can either increase or decrease risk for suicide. My concern for a high-risk client might be overshadowed by the person’s religious beliefs about suicide or by their desire to avoid hurting their children, spouse or parents. “I couldn’t do that to my children” is something that I’ve heard many times from high-risk clients. “My uncle committed suicide, and it devastated my father’s family” is another. Readers might recognize that hope is a mitigating factor, but it is such an important one that it has its own place in my model.

Assessment of Abigail

Abigail’s risk was clear. She was in a high-risk gender, age and diagnostic demographic; she had been contemplating suicide for a very long time; and she had a clear plan. She had been in emotional pain for many years and, most frightening to me, she had little hope of anything ever getting better. Her efforts to improve and the efforts of others to help her, in her estimation, had been futile. She had purchased a poison specifically to have it available if she decided to kill herself (method), and it was presently in her possession (means). I am positive she was motivated to follow through because getting the poison was not easy. She was willing to work hard to prepare for her own death, so I could have little confidence that she wouldn’t follow through. 

Among several mitigating factors in Abigail’s case was that she loved her children and didn’t want to abandon them. Also, she was certain that her religion did not permit suicide, and she feared “an eternity in hell” if she killed herself. Also working in her favor was that she possessed at least enough hope to keep our appointments. She was willing to at least try to let me help her even though she was unsure it was getting her anywhere. She came to therapy several times a week and was willing to trust that life might improve. Finally, she pursued medication for her depression and continued to engage in the business of life. 

Abigail is still alive today, and even though she struggles at times, she reports that she is doing better, that her depression has been managed, and that (now a grandmother) she is finding some happiness in life with her grandchildren.

Conclusions

If I sound overly critical of our profession, it is unintentional. It isn’t that I think we don’t know anything about suicide and risk assessment. On the contrary, there are mounds of data on statistics, risk factors, assessing and so forth. I attended a fantastic education session on suicide risk assessment at the American Counseling Association’s 2018 conference. The session was packed out, the presenters were fabulous, and the information provided was very helpful, but the very nature of the workshop demonstrated that we lack clear standards. Nearly all of us seem to be asking the same question: What do we do?

Without a standard for suicide risk assessment, clinicians face two very serious risks. The first and most important is that failure to standardize may leave our clients at risk for self-harm. Just because we have individualized systems that we believe are working doesn’t mean that they are working. The second issue is self-protection in the event of a lawsuit or a complaint against us with our licensing boards. The existence of best practice standards would allow us to defend ourselves.

Although there is no standard assessment for suicide risk currently, it isn’t beyond our grasp. In the 1990s, the medical community began looking at the use of a research-based protocol in emergency room heart treatment. Malcolm Gladwell described this process in his 2007 book Blink. Physicians resented the simple three-question protocol and were incredulous that anyone would suggest that such a simple tool could offer better triage than their professional experience did. Yet data proved that the protocol was superior in saving lives. The protocol is now standard in the medical field. The same process can be achieved in our field as well, but it depends on our profession’s willingness to study it and to accept the results.

 

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Gregory K. Moffatt is a veteran licensed professional counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University in Georgia. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. He also writes the monthly Voice of Experience column for CT Online. Contact him at Greg.Moffatt@point.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, go to 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.

Behind the Book: Harm to Others: The Assessment and Treatment of Dangerousness

By Bethany Bray June 9, 2015

The most effective solution to rampage violence, such as school or workplace shootings, is early, easy and frequent access to care for potential perpetrators, says Brian Van Brunt, author of Harm to Others: The Assessment and Treatment of Dangerousness.

Counselors play an integral part in this care, through identifying individuals who are at-risk and Depositphotos_31165405_sproviding treatment to move those individuals off the pathway of violence. These two skill sets – assessment and treatment of dangerousness – are essential, yet often lacking in counselor training and education programs, Van Brunt says.

In order to accurately identify individuals who pose a threat, counselors must work against the assumption that mental illness is often coupled with dangerousness or violence.

“Clinical staff typically are asked to assess individuals with mental health disorders who pose a potential for risk to others,” Van Brunt writes in the book introduction. “… ‘Harm to others,’ in other words, is focused more on mental health motivating causes that drive individuals to violence. However, the problem lately has been that many of the individuals being dropped off at the counselor’s office (particularly in K-12 and higher education settings) are making threats or posing a threat to others but have no indication of mental health problems … Although mental illness may be an important contributing factor in any of these [clients], the core of any assessment must be based on threat assessment principals, not clinical pathology.”

Van Brunt, the senior vice president of the National Center for Higher Education Risk Management Group, has a doctoral degree in counseling supervision and education. He is past president of the American College Counseling Association (ACCA), a division of the American Counseling Association.

 

Counseling Today caught up with Van Brunt to talk about his book, Harm to Others, and the importance of the assessment and treatment of dangerousness.

 

What do you hope counselors take away from the book about this topic?

I think there is a dearth of training in our field when looking at the assessment and treatment of those who represent a harm to others. Many graduate and doctoral programs teach suicide assessment and risk assessment, but few focus on the assessment of dangerousness in a way that is based on workplace violence literature. Simply stated, we are well prepared to assess a psychotic patient who is hallucinating and make a determination around commitment or hospitalization, but not prepared very well to assess the high school student who threatens to “go all Columbine” if they don’t have a grade on their final paper changed from a D to a C.

My book provides counselors clear and practical guidance on the fundamentals of how to conduct a violence risk assessment. Harm to Others closes the knowledge gap for new and seasoned clinicians being asked to conduct these kinds of assessments and work with challenging, hostile and difficult patients.

 

In your opinion, what makes professional counselors a “good fit” for violence assessment and training? What unique skills do they bring to the table?

I’d suggest a willingness to learn about how to do this important work in a research-supported manner. In my experience, an enthusiasm to learn more about violence and risk assessments is much more critical than an advanced academic degree. Many in the threat assessment community come from law enforcement or counseling backgrounds and have learned how to complete risk and threat assessments through on-the-job training, individual scholarship through workplace violence books and articles, and training through organizations such as the Association of Threat Assessment Professionals (ATAP) and the National Behavioral Intervention Team Association (NaBITA). But the underlying connection for a “good fit” tends to be a willingness to devote the time and energy to this scholarship.

This can create a bit of a challenge since there is no current licensure or certification standard when it comes to violence risk or threat assessment, so there is no objective standard of what makes a good threat assessment that exists in the law enforcement or psychology field at this time. As with clinical licensure and certification, a focus on research-informed practice, adherence to ethical standards found in both psychology and law enforcement, individual supervision and hands-on experience would be the four pillars I would suggest when preparing to do this kind of work.

I would also suggest the ability to build rapport and lower an individual’s defenses is critical in this work. Forming an attachment with the person who is being assessed is key to obtaining accurate data in order to build a valid risk or threat assessment. Crisis and emergency clinicians, those who work with personality disorders in their client caseload, family therapist and those who assess and treat teenagers often have skills in developing rapport and connection in difficult and adverse conditions.

 

 

What are some misconceptions you feel counselors have about dangerousness in clients?

I think one of the biggest problems that leads to misconceptions is an over-reliance on mental health diagnosis when it comes to assessing or treating dangerousness. There is an assumption that mental health problems such as depression, autism spectrum disorders (ASDs), post-traumatic stress disorder (PTSD) or anxiety leads to dangerousness or violence. This is one of the reasons I stress a solid overview and study in the field of threat and violence risk assessment. This is a problem beyond mental health concerns. And this distinction is often a difficult one for the public or untrained clinician to always appreciate. For example, the diagnosis of depression isn’t a central risk factor for targeted violence; instead we look at hopelessness and desperation. The diagnosis of ASD isn’t the concern; it’s the potential accompanying social isolation that prevents the assessment of the escalating threat.

There is also the distinction between ‘being a threat’ and ‘making a threat.’ This is often a source of difficulty for those new to this work. While direct threats are always cause for concern, the follow up assessment of the lethality of this threat becomes paramount. While all of us understand we would be concerned with someone at work who tells his supervisor “I’m going to come into work tomorrow with a katana sword and go all Kill Bill (the Quentin Tarantino films about an assassin) on you,” the real assessment here comes in understanding issues of weapons access, action and time imperative, fixation and focus on target and similar risk factors. I reference many of these factors in Harm to Others and refer frequently to the giants in the field such as Reid Meloy; Stephen Hart; Mary Ellen O’Toole; Michael Gelles and James Turner; and Frederick Calhoun and Stephen Weston to help counselors develop a deeper understanding of the questions they should be asking when assessing or treating a potentially violent client.

 

 

Do you feel today’s counselors are coming out of graduate school with adequate training/knowledge of violence assessment and treatment?

Unfortunately, the answer is no.

There are a number of excellent programs out there such as George Mason University’s forensic program chaired by Mary Ellen O’Toole and Alliant International University’s program under Eric Hickey in California, but assessing and treating potential dangerousness in clients is an issue that hasn’t yet been included in most psychology graduate programs. There certainly is a focus on crisis counseling, assessing suicidality, conducting mental health assessments and assessing and treating violence in higher risk clients with bi-polar, substance abuse, or psychotic disorders, but none of this really gets to the underlying core of work on violence and risk assessment that exists in the professional literature on workplace violence.

 

What would you want all counselor practitioners — marriage counselors, addictions counselors, mental health counselors, etc. — to know about violence assessment and treatment?

Well, first, I would suggest an understanding that these are two different skill sets. Assessing a potential threat is different than on-going therapy and treatment with a potentially violent or dangerous client.

Second, I would want all licensed clinicians to at least have a basic understanding of the risk factors related to targeted or rampage violence. If I was in a room of counselors and I asked what the risk factors were for suicide, I would quickly get a response. They would tell me being a male, age 18 to 22 years old. They would talk about lethality, access to means, prior attempts, situational stressors and having a plan. Suicide risk factors are well taught and well understood not only by clinicians; even the lay public has a foundational knowledge of what to look for if they were concerned about a potential friend or colleague who might be suicidal.

When it comes to risk factors that indicate a potential for harm to others, I think most clinicians draw a blank. They may guess at social isolation or wearing all black. They may suggest an anti-social tendency or disenfranchisement. They may talk about being on medication or playing violent video games. But few clinicians have a good understanding of what risk factors are supported by literature to better understand the risk of rampage or targeted violence. In Harm to Others, I provide several lists of these risk factors with practical examples of how to assess and mitigate these items to help prevent future violence.

While we do not excel at predicting violence; this remains a holy grail for the violence risk and threat assessment field. While we will never develop an accurate model of violence predication, we can certainly identify risk factors and prevent violence. Think of the risk factors of a heart attack. We understand these well: lack of exercise, being obese, hereditary factors, poor diet, and smoking. Each of these risk factors are targeted by public health prevention and education programs to reduce the risk of a heart attack. Yet, we can’t predict a heart attack. This is how we should think about identifying the risk factors for rampage or targeted violence. Our goal becomes prevention and intervention, rather than predication.

 

In the book introduction, you write, “The most effective solution to rampage violence is early, easy and frequent access to care for potential perpetrators.” In your opinion, how can counselors play a role in this access to care?

Quite frankly, we need to become that care. The reality is those who most need to be in counseling to change the path to violence they are on are the least likely to show up and remain connected to care.

It reminds me of the streetlight effect — the old story about the drunk man looking for his keys. It goes like this: A policeman sees a drunk man searching for something under a streetlight and asks what the drunk has lost. He says he lost his keys and they both look under the streetlight together. After a few minutes the policeman asks if he is sure he lost them here, and the drunk replies, no, and that he lost them in the park. The policeman asks why he is searching here, and the drunk replies, “this is where the light is.”

Most of us spend our time providing therapy with those clients who voluntarily come in for treatment, but those in real need, those who have lost hope and find their only solace by sitting alone andSecurity business man avoid danger risk planning these kind of horrific attacks, are not connected to care. Our mental health system fails them under the guise of individual rights. We do not have an adequate step between voluntary outpatient care and involuntary inpatient commitments.

We need a mental health system in the United States that functions more like our child protective service system. When a child is found at risk, an investigation occurs and a caseworker is assigned. The case remains open until the risk is mitigated. We don’t have a system like that for violence risk to others. Too many times we end up shaking our heads saying things like “Well, we all are concerned, but there is nothing we can do until the person breaks the law or threatens someone.” We say, “They need to be in counseling, but they aren’t an acute danger to themselves or others, so we can’t mandate or force the issues.” We need to address this gap. Without the ability to require care once the risk factors are identified, there is little hope to reduce targeted violence.

And of course, this raises the specter of Big Brother. The recent National Security Agency (NSA) scandal doesn’t help matters much either. Yet, we are willing to take away individual rights of parents when a child is at risk. I struggle with why we don’t have a similar mechanism in place when there is an individual who has many of the risk factors, yet hasn’t broken any laws or doesn’t meet commitment criteria. We need to address this Goldilocks problem when the porridge is neither too hot nor too cold. How do we attend to the student everyone is concerned about, but hasn’t yet broken the law or school conduct code?

 

 

What advice would you give to a counselor who wants to work on/improve their violence assessment and treatment skills? What resources would you point them toward?

There are three trainings that I would recommend for a counselor looking to improve their skills in violence risk assessment.

  • The Association of Threat Assessment Professionals was the place I started my journey in the area of threat assessment. They offer an amazing conference each August in Anaheim, California.
  • My organization, NaBITA also offers detailed training in violence risk and threat assessment and we hold our conference annually; this fall it is in San Antonio.
  • Stephen Hart also offers a wonderful set of trainings and workshops on the topic of Structured Professional Judgment (SPJ) through the company Proactive Resolutions.

If attending a conference or training is outside of your budget, I would suggest the following three books that have been very useful in my personal training and experience in violence risk and threat assessment.

  • The first is Reid Meloy and Jens Hoffmann’s International Handbook of Threat Assessment (2013). This collection of articles provides the reader with a sound overview of the current state of the field.
  • The second book is by Michael Gelles and James Turner: Threat Assessment: A Risk Management Approach (2003). This book is a very accessible starting place for those interested in the process of threat assessment.
  • The final book would be Mary Ellen O’Toole’s book Dangerous Instincts (2012). This text offers uncanny insight into the world of identifying and assessing threat.

 

What inspired you to write this book?

I’ve written several other books that circled this topic. Ending Campus Violence: Prevention Strategies and New Approaches to Prevention (2012) was written to a college and university administration and student affairs audience. A Faculty Guide to Disruptive and Dangerous Behavior in the Classroom (2013) was written to faculty who wanted better guidance on managing classroom behavior and identifying dangerous students.

This book, Harm to Others came from frequent requests (I’ve received) at trainings from counselors and psychologists around the country who are being asked to conduct violence risk assessments on their clients. This book provides them with a practical guide full of examples and additional resources to better assess and work with dangerous individuals.

 

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About the author

 

Brian Van Brunt is president of the National Behavioral Intervention Team Association and senior vice president of the Pennsylvania-based National Center for Higher Education Risk Management (NCHERM) Group, a law and consulting firm that addresses risk management issues in educational settings. An author of several books, he is a frequent speaker and trainer on issues of threat assessment, mental health and crisis management across the globe.

Van Brunt has a doctoral degree in counseling supervision and education from the University of Sarasota/Argosy and a master’s degree in counseling and psychological services from Salem State University in Massachusetts.

 

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Branding-Box_Van-BruntHarm to Others: The Assessment of Treatment of Dangerousness is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

 

 

 

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For more information

Brian Van Brunt was also interviewed for a recent American Counseling Association podcast, titled “Harm to others.” Listen to the hour-long podcast here: counseling.org/knowledge-center/podcasts/docs/default-source/aca-podcasts/ht052—harm-to-others

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Case study: The critical need to conduct thorough child assessments

By Gregory K. Moffatt January 29, 2015

“Amanda” sat on the couch across the room from me drawing on a sketch pad. A lovely young girl of 14, she weighed scarcely 100 pounds, and with her cheery and naïve smile, she looked as innocent as they come. If I hadn’t seen attachment disorders many times before, I could easily have been swingsfooled by her carefree air and seemingly open-book candor.

Could this barely pubescent teen really have done what she had been accused of? In my work, I have seen dozens of children who have been accused of animal cruelty, rape and even murder. I knew better than to be fooled by the crafty façade of which children such as this are capable.

 

The case

The call on my cell phone was from a social worker at a foster care agency. As I drove through Atlanta traffic, she explained that two family pets had been horribly violated in a sexual way, with injuries so serious that both dogs had required surgery. The county sheriff’s department was investigating the case, and Amanda was the prime suspect.

Amanda’s background was classic for reactive attachment disorder (RAD). Very early in life, she had been abused both physically and sexually, at which time she was removed from her biological parents’ home and placed in foster care. Early attachment problems were present in her case file, including sexual acting out and some indication of cruelty to animals.

Circumstantial evidence pointed to Amanda as well. She was the caretaker of the pets and was often unsupervised. She was the last person seen with the dogs before their injuries, and her home was in a remote, rural area, making it unlikely that some random perpetrator was at fault.

My heart sank. I felt certain I had another case of a seriously disturbed child, and I made an appointment to do an assessment with Amanda within the next few days.

But things are not always what they seem.

 

The assessment

I easily could have conducted my in-office assessment with Amanda, written my report, submitted my bill and been done with it. But this would not have given me the fullest picture of Amanda and the extenuating circumstances this situation presented.

Prior cases such as Amanda’s that I had worked were clear. Children with RAD often begin displaying disturbing behavior in early childhood, sometimes even in infancy. These behaviors become progressively worse until parents or guardians eventually run out of ideas for coping. By the time they come to my office, these children have often sexually assaulted other children, destroyed property or become incorrigible. None of these things were true for Amanda.

My normal assessment includes, among other things, a number of processes that allow me to observe a child’s sexualization, socialization and attachment. In cases such as this, I also normally conduct a minimum of two different assessment appointments. Children may behave very differently from one day to another, and this practice has helped me avoid many problems over the years.

Amanda passed these assessments with flying colors. I was at a loss because cursory information made her the most likely suspect, but what I saw in my assessment was inconsistent with a young teen who could have so cruelly abused an animal in such a sexual way.

Looking through nearly 10 years of Amanda’s evaluations by psychologists, I found hints of sexualization and cruelty to animals as I had initially been told, but careful reading put this information in a different context. In the child’s early years, there had, indeed, been evidence of sexual acting out as one might see in children with RAD. But interestingly, no one had observed even a single instance of Amanda acting out sexually since she was 6 years old —a span of longer than eight years.

The “cruelty” to animals that existed in her file was, in my opinion, either a very mild form of cruelty or not cruelty at all. Children often hurt animals, sometimes in very serious ways, but my concern is not with the seriousness of the injury. A normal child might seriously injure or even kill a pet by accident. A child with RAD, on the other hand, might torment and torture a pet explicitly for the purpose of causing pain, even if the pet doesn’t end up being seriously injured. These are very different motives. I saw no clear evidence of “cruelty” in the recorded behaviors in Amanda’s file.

But this evidence can be deceptive. Children with RAD often mask their cruel behaviors against both animals and people as seemingly innocent mistakes. I had to be certain I wasn’t missing something with Amanda.

 

Interviews and supporting information:

I needed a fuller picture of Amanda than I could achieve from my office evaluation and the information in her file. One of the many professional hats I wear is that of a homicide profiler. When I am looking at a homicide case, I want to know as much as I can, not only about the homicide but also about the victim, the place, the weapon and the timing of the event. I interview as many people as I can and look at every piece of evidence available to me. In ethnographic research, this is called triangulation (looking at evidence from three or more sources), and Amanda’s case demanded this type of multidirectional examination. I didn’t want to make a decision based simply on my office assessment.

I started my interviews with the foster parents. I needed to know more about Amanda’s history in the nine years they had had guardianship of her, and specifically about the past three or four years. This caring and loving couple had treated Amanda like a daughter since her placement in their home, and they were certain she was innocent. I knew they could be biased in their perceptions, but unless they were trained to know what I was looking for, they couldn’t easily manipulate my impressions.

I was looking for any symptoms of sexualization or cruelty in Amanda’s recent history. RAD doesn’t go away by itself, and it doesn’t improve with time. Instead, the symptoms digress. If Amanda had been cruel to animals early in life, she almost certainly would not stop, and the cruel behavior would escalate. Likewise, if she truly was a child with RAD and she had acted out sexually early on, she would still be engaging in sexual behaviors, and those behaviors also would have escalated. Cruelty moves through a digression — objects to animals and then animals to people. Sexual behaviors digress as well — masturbation, sexual exploration, acting out with consenting others and, finally, acting out on others by force.

Children might easily “practice” their sexual exploitation on animals before moving to humans because animals are easier to control. If Amanda had done something so overtly sexual and cruel to the two family pets, there would have to be symptoms of cruelty and sexualization in her recent history. But my interview with her parents turned up no such allegations in any context, at any time, from any teacher, playmate, sibling, coach or therapist.

I was also interested in Amanda’s ability to connect with other human beings — to show and receive affection. Children with RAD have trouble with both. The comments of the foster parents were consistent with what I had observed in my evaluation. Amanda had no troubles connecting in any context — school, church, athletics or home. She seemed to be a loving child who, although socially awkward, got along well with others and would not intentionally hurt anyone or anything.

I also needed the investigative perspective of the sheriff’s deputy, even though I knew he was already convinced that Amanda was to blame. For good reason, he saw no other logical suspect and had focused all of his investigative resources on her, but he was waiting for my evaluation before proceeding. He provided me with the basic facts of the case. During our first conversation, I derived a clearer picture of how this event could have taken place. The timing of events and other facts confirmed the information I had received from the foster parents. This confirmation was very important because it allowed me to dismiss the possibility that they were attempting to deceive me. It also helped me create a visual image of the event and give further consideration to how Amanda might have injured these dogs without being detected as well as how difficult that might have been for her to do.

Armed with that information, I realized it was at least possible that Amanda was just beginning to exhibit cruel behavior. I needed to know what the dogs experienced, so, with the consent of my client, I called the veterinarian who conducted the surgeries. My main question: Would someone have known she was hurting these animals, or would the animals simply have stood still and allowed the abuse? After all, Amanda was tiny, and these were large, full-grown dogs. Could she have restrained them?

The vet said the dogs would have been howling, struggling and whimpering. “No question,” he said. “The perpetrator would have known these dogs were in serious pain.” This was consistent with the idea of children with RAD intending to do harm, but it left me wondering how Amanda could have controlled the dogs long enough to do this.

I wanted a second opinion. I called a university with a respected veterinary program and talked to the department chair. I sent him photographs of the objects used in the abuse and gave him a summary of the case. His answer to my question? The dogs would have simply stood there and accepted the abuse! The perpetrator may not have known that he or she was causing serious, life-threatening pain, he said. This could be consistent with a child just beginning to act out on animals and didn’t exonerate Amanda.

I now had two completely opposing opinions, so what could I do? I chose to dismiss the “pain” component because I couldn’t be certain which veterinarian to believe. What was uncontested was the fact that both female dogs had large objects inserted into their vaginas. This was clearly a sexual behavior. Most adults couldn’t even find a dog’s vagina. The most obvious rear orifice in a female dog is the anus. This told me that this perpetrator had to deliberately seek out the vagina. Therefore, this was almost certainly not the first time he or she had acted out sexually, which was inconsistent with Amanda’s history. Was it possible for a child to go from simple “show me yours” sexual acting out nine years earlier to vaginally violating not one but two animals at the same time? I hardly saw that as possible.

 

Conclusions

After nearly two weeks of study, interviews, telephone calls and assessments, my final conclusion was that Amanda had nothing to do with the abuse to these animals. I believed that the loving and caring foster family had helped her weather a very difficult start to her life and their interventions had been effective in counteracting the problems of early attachment issues. Amanda measured low normal in IQ, and it seemed inconceivable to me that she could be cunning enough to hide this type of serious dysfunction from everyone in her environment for so long. Although it wasn’t impossible, it was highly improbable.

It was my recommendation that the foster care agency carefully investigate other possible perpetrators among the children in the home and that the sheriff’s department look into other possible suspects from nearby homes as well as hunters or others who might be known to be in this remote area. In my final telephone call with the investigating officer from the sheriff’s department, he asked me the obvious question: “If this child didn’t do it, then who did?” Occam’s razor tells us that the simplest solution is most often the correct one. That just wasn’t the case here. I didn’t want to sound trite, but the person he should investigate really wasn’t my problem, and I said so, although not so bluntly.

Still, I remained tentative in my final evaluation. The risk to others was very high if I was wrong. Therefore, I proposed that Amanda be reevaluated at six months, and I also recommended that she be evaluated by an expert in dissociative identity disorder (DID). The only way I could fathom her possibly committing such acts and yet successfully hiding them from everyone for so long was the remote possibility of DID. I suggested that either I was right and Amanda had nothing to do with this incident, or I was wrong and she was the most clever, sly and dangerous child I had ever seen in my practice.

So, why couldn’t I have simply skipped all the phone calls and gone with my initial evaluation? After all, it appears that I was correct, wasn’t I? Yes, but a possibility certainly existed that I was wrong, and the risk that posed to Amanda, her family, animals in her environment and others was scary. If I had concluded that Amanda was not the perpetrator and was wrong, she would have been free to act out on other animals. In addition, this behavior was so cruel that it would have been a very small step for her to act out on humans, including younger or weaker siblings or playmates. She would have been a risk to everyone she came into contact with.

On the other hand, if I concluded that Amanda did in fact commit this act, she would have been removed from the home. She had lived in this stable, loving home for most of her life, and if my conclusions were wrong, she would have been unfairly uprooted, stigmatized and very difficult to place in the foster care system. The progress she had made might quickly have been undone, and my mistake could have had lifelong consequences for her. Both of these possible outcomes had serious consequences.

 

Follow-up

One year later, my conclusions seem to have been proved correct. The follow-up for DID resulted in no indication of multiple personalities, and the psychologist’s conclusions were the same as mine. Subsequent evaluations also rendered conclusions consistent with my original evaluation, and no other incidents have occurred in the family home or environs. To my knowledge, no other perpetrator has been pursued or apprehended.

This case presents four very important lessons for counselors:

1) Cover every base. Avoid the temptation to lean too heavily on any single piece of information or assessment for conclusions. Assessment processes, interviews, case material and other sources of information can provide triangulation and help confirm or disconfirm information that might be presented in a child’s file.

2) Material in case files may not be objective, and there may be other ways to see the behaviors recorded therein. Read these files with objectivity and caution.

3) Be tentative in your conclusions.

4) Follow up for certainty. If I had been wrong in this case, my recommended follow-up could literally have saved someone’s life.

 

 

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Gregory K. Moffatt is a professor of counseling and human services at Point University. A licensed professional counselor, he has more than 25 years of clinical experience treating trauma with children. Contact him at Greg.Moffatt@point.edu.