A Five Stage Model for Counselling Men

IntroductionSad man

This year I was honoured to be a panelist at the “Healing Journeys: Violence and Trauma Conference Focusing on Male Victims” by the Canadian Centre for Men and Families. I sat in on a panel discussing the needs of men, and had an opportunity to discuss the influence of men and suicide. It was a wonderful learning and networking opportunity.

We know that men have smaller social circles than women (McPherson, Smith-Lovin & Brashears, 2006) and they seek help less often (Courtenay, 2011; p. 13). Finding male therapists is also difficult (Carey, 2011), which can complicate things for men experiencing current or historical intimate partner or sexual violence.

Below is a model for counselling men from the second chapter of “Counselling Fathers from a Strength-Based Perspective” in Counselling Fathers (Oren, et. al., 2010; p.30.) Although this model was originally designed for working with fathers I believe it is equally applicable to working with men who are not fathers.

Five Stage Model for Counselling Men
Five Stage Model for Counselling Men

The five stages are:

  1. Rapport and Therapeutic Alliance
  2. Assessment
  3. Identification of strengths
  4. Interventions
  5. Resiliency and Termination

Each of these will be reviewed below.

Rapport and Therapeutic Alliance

The first element of any therapy or counselling is establishing a strong therapeutic relationship. The SOLER elements of active listening (Egan, 2007) can be useful, although with a change noted below. There are also some things that can be used to establish rapport when counselling men or boys (Kiselica, 2003), including:

  • Displaying magazines relevant to men’s issues (sports, hunting/fishing, men’s health and fitness)
  • Flexible scheduling for appointments (shorter or longer to allow time for building rapport without getting tiring)
  • Using humour and self-disclosure
  • Sitting side-by-side rather than across from each other
  • Setting goals and working collaboratively
  • Using client-centered language

Kiselica also notes that traditional models of engaging with clients (especially young boys) may be ineffective, and that a more instrumental, active or group-based process may be useful.

Assessment for Counselling Men

A strength-based assessment (Graybeal, 2001) acknowledges the overlooked assets that men bring into the counselling relationship, rather than focusing on problems or challenges. This continues into the next stage (identification of strengths). In addition to identifying strengths, the concept of gender role conflict should be explored.

Gender role conflict (O’Neil, 2008) is defined as “a psychological state in which socialized gender roles have negative consequences for the person or others” and involves six elements (O’Neil, 1981) that have commonly be forced upon men:

  1. Restrictive emotionality – The inability of men to express their emotions (often because of society or familial prohibition)
  2. Health care problems – Men are less likely to seek help for their physical or mental health problems
  3. Obsession with achievement and success
  4. Restrictive sexual and affectionate behavior – Related to restrictive emotionality, men are sometimes prohibited from being affectionate with other men
  5. Socialized control, power, and competition issues – Men are socialized to pursue control, power and achievement at any cost, while men who choose a different path (for instance, by parenting) are considered weak or un-masculine
  6. Homophobia – Men who fear being called gay may be less likely to pursue heterosexual friends

By developing a deep understanding of the conflicts your client is experiencing you will be better able to identify strengths and plan appropriate interventions in the next stages.

Identification of Strengths

Identifying strengths is paramount to a positive therapeutic environment when counselling men, especially for men who have been rejected by therapists in the past. Some positive male qualities include (Oren, et. al., 2010; p.59):

  • Altruism
  • Courage
  • Generativity (Slater, 2003) – the concept of leaving your mark
  • Perseverance
  • Protection of others
  • Responsibility
  • Service

These and other values (self-sufficiency, achievement, efficiency, loyalty, and pride) can help build often-fragile male self esteem and provide a framework for intervening.

Interventions for Counselling Men

Now that you’ve performed a comprehensive assessment and you have an understanding of your client’s values, strengths, and what gender role conflict they may be experiencing you are ready to begin planning effective interventions while counselling.

Exploring times in the client’s past when they were able to cope with the problems they’re experiencing now and allowing them to narrate the stories in their life. (Smith, 2006)

Employment is often an area where men succeed, even as they are challenged in their personal life. Using work as a metaphor, men can apply the attitudes of being assertive, prioritizing, building relationships, and so on. Applying these lessons and potentially hidden skills to their personal life can help men improve their ability to deal with problems at home.

Mahalik (1999) used the concept of gender role strain – the idea that men are not living up to their gender or masculinity requirements – to help assessing and working through cognitive distortions. He suggested some strategies for changing cognitive distortions:

  1. Explore how men experience cognitive distortions as adaptive or positive instead of negative; for example, a man who values hard work in their career over everything else may experience positive career and financial benefits at the expense of their relationships with their family
  2. Examine the connection between gender role and these cognitive distortions
  3. Practice experiments to confirm or deny the accuracy of these distortions
  4. Provide more accurate beliefs to replace the distorted ones

Throughout the counselling process it’s important to recognize the impact that gender roles has on someone’s behaviour. Gently challenging these and other beliefs (like those around social support or emotional expression) and encouraging new ways of men expressing themselves are ways of working through the intervention stage. (Oren, et. al., 2010; p.145)

Resiliency and Termination

The final stage in counselling men is resiliency and termination. This starts with identification of male-positive resources or institutions such as programs to promote healthy marriages or healthy children (Oren, et. al., 2010; p.38) and finding other more informal supports in the client’s life such as friends, family, coworkers and professionals like doctors, coaches and clergy.

Finally, modelling elements of good termination in general counselling can help the client terminate other relationships (such as with partners) in their personal life more effectively. These elements include (Hardy & Woodhouse, 2008):

  • Highlighting the positives of ending sessions
  • Providing an open discussion
  • Ensuring both client and therapist are prepared for the end of therapy


Carey, B. (2011, May 21) “Need therapy? A good man is hard to find” Retrieved on October 22, 2016 from http://www.nytimes.com/2011/05/22/health/22therapists.html?_r=2

Courtenay, W.H. (2011) Dying To Be Men: Psychosocial, Environmental and Biobehavioral Directions in Promoting the Health of Men and Boys. Routledge: New York, NY.

Egan, G. (2007) The Skilled Helper: A Problem Management Approach to Helping. 8th ed. Thomson Brooks/Cole: Belmont, CA.

Graybeal, C. (2001). Strengths-Based Social Work Assessment: Transforming the Dominant Paradigm. Families In Society,82(3), 233-242.

Hardy, J. A. & Woodhouse, S. S. (2008, April). How We Say Goodbye: Research on Psychotherapy Termination.  [Web article]. Retrived from http://societyforpsychotherapy.org/say-goodbye-research-psychotherapy-termination

Kiselica, M. S. (2003). Transforming psychotherapy in order to succeed with adolescent boys: Male-friendly practices. Journal of Clinical Psychology, 59(11), 1225–1236.

Mahalik, J. R. (1999). Incorporating a gender role strain perspective in assessing and treating men’s cognitive distortions.Professional Psychology: Research And Practice, 30(4), 333-340. doi:10.1037/0735-7028.30.4.333

McPherson, M., Smith-Lovin, L., Brashears, M.E. (2006) Social Isolation in America: Changes in Core Discussion Networks Over Two Decades. American Sociological Review. 71(3).

O’Neil, J. M. (1981). Patterns of gender role confl ict and strain: Sexism and fear of femininity in men’s lives. Personnel and Guidance Journal, 60 , 203–210.

O’Neil, J. M. (2008). Summarizing 25 years of research on men’s gender role confl ict using the gender role conflict scale: New research paradigms and clinical implications. The Counseling Psychologist, 36 (3), 358–445.

Slater, C.L. Journal of Adult Development (2003) 10: 53. doi:10.1023/A:1020790820868

Smith, E. J. (2006). The strength-based counseling model: A paradigm shift in psychology. Counseling Psychologist, 34(1), 13-79.

Oren, C.Z., Englar-Carson, M., Stevens, M.A. & Oren, D.C. (2010) Counselling Fathers. Routledge: New York, NY.

Cite this article as: MacDonald, D.K., (2016), "A Five Stage Model for Counselling Men," retrieved on October 25, 2016 from http://dustinkmacdonald.com/five-stage-model-counselling-men/.
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Law Enforcement Suicide Prevention


Organizations like the Tema Conter Memorial Trust in Canada and Reviving Responders in the US have highlighted the skyrocketing rate of suicide among first responders, including police officers, paramedics and firefighters. In 2015, there were over 100 suicides by law enforcement officers in the US. (Kulbarsh, 2016) They note the high incidence of PTSD among law enforcement officers and the stigma that prevents them from seeking support.

One way to reduce law enforcement suicide is through police academy training that provides all officers with suicide awareness training. This helps reduce the stigma of receiving mental health support and gives police the opportunity to act as peer supporters for their colleagues.

Overview of Curriculum

The material below comes from the Basic Course for Police Officers authored by the New Jersey Police Training Commission (2016). This 262-page manual provides a complete review of the curriculum that police officers in that state learn during their 24 weeks at the Academy.

One of the instructional units is named “Suicide Awareness and Prevention for the Law Enforcement Officer”. The description is as follows:

The trainee will understand the causes, symptoms, warning signs and risks associated
with officer suicide, and will identify appropriate intervention and prevention strategies
to effectively deal with this issue.

The outcomes of this module are as follows. Once completed, the police recruit will be able to:

  • Define suicide
  • Identify demographics associated with law enforcement suicide
  • Know stressors that contribute to suicide
  • Explain risk factors associated with suicide
  • Identify warning signs associated with suicide
  • Understand suicide myths
  • Explain and apply the AID LIFE acronym for intervening with suicide
  • Identify obstacles to effective suicide intervention
  • Note professional resources helpful to an officer
  • Identify strategies to prevention law enforcement suicide

The content from these modules is summarized below, but I’ve added references where appropriate to back up the un-cited information. The goal is to provide added-value and confirm the veracity of the material.

Defining Suicide

Suicide is defined as the intentional taking of one’s own life (Stedman, 2016).

Demographics of Law Enforcement Suicide

  • There are more deaths to police suicide than in the line-of-duty (Kulbarsh, 2016)
  • The police officer life expectancy is less than the general population (Violanti, 2013)
  • The suicide rate is approximately 14 deaths per 100,000 (Badge of Life, n.d.) compared to 13 per 100,000 in the general population (AFSP, 2014)
  • Although the curriculum maintains that the divorce rate is higher among police officers, the opposite is actually true. The divorce rate is slightly lower, at 14.47% versus 16.96% for all professions over the lifetime (Roufa, 2015)
  • The rate of substance abuse is higher among police officers (Cross & Ashley, 2004)

Stressors Contributing to Law Enforcement Suicide

In addition to the normal stressors such as depression, anxiety, substance abuse and relationship issues, the curriculum identifies some specific job-related stressors. These include:

  • Discipline issues (internal affairs and/or
    criminal investigations); and
  • Management issues (assignment – lack of promotion – supervision);
  • Retirement (loss of identity and sense of belonging).
  • Shift work;
  • Sleep deprivation;
  • Unfulfilled job expectations;

Risk Factors Associated with Law Enforcement Suicide

This section identifies historical, demographic risk factors that may increase suicide. These are listed below, and correspond to those in the SAD PERSONS Scale and the CPR Risk Assessment:

  • Knowledge of and access to lethal means;
  • Age;
  • Gender;
  • Ethnicity;
  • Previous history (self or family member);
  • Cumulative stressors;
  • Feeling of hopelessness and helplessness; and
  • Lack of intervention resources.

Warning Signs of Law Enforcement Suicide

Warning signs, as defined by the AAS (n.d.) are items that represent an imminent, increased risk (active factors) rather than the stable historical factors that don’t necessarily represent increased risk. For instance, being a male does not itself mean someone is suicidal, but being a man does increase the chances someone will die.

The warning signs listed in the curriculum (reproduced verbatim below) represent a mix of risk factors and AAS-type warning signs.

  • Depression:
    • Attitude of hopelessness and helplessness;
    • Unexplained changes in appetite, weight, appearance, and/or sleep habits;
    • Difficulty making decisions;
    • Difficulty concentrating;
    • Overly anxious;
  • Previous suicide attempt;
  • Increase in the use of alcoholic beverages;
  • Overly aggressive or violent behavior;
  • Any changes in mood or behavior that are out of the ordinary, including a neutral mood;
  • Changes in work habits;
  • Behavioral clues of suicidal thoughts:
    • Giving away possessions;
    • Making a will;
    • Talking about a long trip;
    • Sudden interest or disinterest in religion;
    • Substance abuse relapse; and
    • Taking inappropriate duty-related and personal risks.
  • Anger / irritability; and
  • Concern expressed by family / friends / colleagues about a specific individual;

Identifying Common Suicide Myths

The myths that are discussed here include:

  • People who talk about suicide won’t attempt
  • Talking about suicide with someone does not reduce their risk
  • Warning signs are not present before a person dies by suicide
  • Suicidal individuals must have a mental illness
  • Suicidal individuals are beyond help
  • Suicidal individuals are committed to dying

See my article on suicide myths for a more complete discussion of these

AID LIFE for Suicide Intervention

AID LIFE is an acronym that is given in the training for a simple intervention procedure. The steps in AID LIFE are as follows:

  • A – Ask if the individual is thinking about suicide
  • I – Intervene immediately. Listen and let the person know they are not alone.
  • D – Don’t keep their suicidal thoughts a secret. Seek assistance
  • L – Locate help. This can include a supervisor, chaplain, physician, or other members of their support network. (Including crisis workers or the Emergency Room.)
  • I – Inform the Chain of Command. This can help get important resources like counselling in place.
  • F – Find someone to stay with the individual. (Dustin’s note: I’m actually not a big fan of this one, it shows up in the Marine Corps suicide awareness program as well; this is more important for high-risk, imminent suicide than it is for someone who may be low or moderate risk.)
  • E – Expedite. Get help now, rather than delaying it.

Obstacles to Effective Suicide Intervention

These obstacles are reproduced directly from the manual and include a variety of police-specific and more general obstacles to effective intervention with police officers who are struggling with suicidal thoughts.

  • Fear of stigma, isolation, humiliation, suspension, job loss;
  • Fear of change in duty status;
  • The police culture; (seeking mental health support may be perceived as a character weakness)
  • Denial that there is a problem; (by the officer, peer officers, supervisors, the command staff)
  • Reluctance of the officer to seek help for fear of the officer losing control of the situation;
  • The officer’s fear that confidentiality will not be maintained;
  • The officer’s distrust of management;
  • Supervisors and peers who protect or shield a troubled officer; and
  • Lack of knowledge by a troubled individual about the availability of counseling resources, and concern about being able to afford such services.

Professional Resources for Law Enforcement Suicide

Although this is a New Jersey Police manual, the resources presented are general enough to be a good reference. The resources that are recommended include:

  • Crisis Line
  • Employer Assistance Program (EAP)
  • Faith-based support (e.g. Chaplain or Church official)
  • Hospital emergency room
  • Mental Health Counselling (in person or otherwise)
  • Peer Support (from another officer or supervisor)

Strategies to Prevent Law Enforcement Suicide

The following 4 strategies are generally recommended for preventing suicide by both law enforcement officers and the general public. They include:

  1. Understanding the risk factors and warning signs of law enforcement suicide
  2. Using available resources and building a support network
  3. Challenging the stigma in seeking support
  4. Using the AID LIFE mnemonic

Other Police Suicide Prevention Programs

Together for Life was developed by Psychologists as a comprehensive suicide prevention program in Montreal. This program includes a half-day training session for all officers, a confidential telephone helpline, a full-day training session in more in-depth techniques for supervisors and awareness materials. Mishara & Martin’s 2012 evaluation showed:

  • 99% of those who attended the sessions said they would recommend the sessions to a colleague
  • 84% of supervisors were aware of the program
  • Positive increases in knowledge of risk factors and warning signs, and how to intervene
  • A nearly 80% decrease in the rate of Montreal police suicides (versus no change in the rate of police suicides in other police services in Quebec)

Badge of Life: Psychological Survival for Police Officers (Levenson, O’Hara & Clark, 2010) makes “emotional self-care (ESC)” the focus of a series of training modules delivered to police officers, along with mental health screenings and the delivery of peer support by other officers and the use of Critical Incident Stress Debriefing (CISD).

Police Organization Providing Peer Assistance (POPPA) (Dowling, et. al., 2006) is a New York Police Department (NYPD) based program for preventing suicide. It combines a confidential helpline, support groups, printed suicide awareness and intervention materials distributed to all police officers, and tools to assess resiliency and stress. Applied Suicide Intervention Skills Training (ASIST) is also provided yearly.

Additional Resources

The book Police Suicide: Tactics for Prevention provides a comprehensive review of police suicide causes and potential interventions to reduce suicidal behaviour in this group.


American Association of Suicidology. (n.d.) “Warning Signs | American Association of Suicidology” Retrieved on September 4, 2016 from http://www.suicidology.org/resources/warning-signs

American Foundation for Suicide Prevention (AFSP). (2014) “Suicide Statistics — AFSP” Retrieved on September 4, 2016 from https://afsp.org/about-suicide/suicide-statistics/

Badge of Life. (n.d.) Police Suicide Myths. Retrieved on September 4, 2016 from http://www.badgeoflife.com/myths/

Cross, C.L. & Ashley, L. (2004) Police Trauma and Addiction: Coping With the Dangers of the Job. FBI Law Enforcement Bulletin. 73(10) Retrieved on September 4, 2016 from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=207385

Dowling, F.G., Moynihan, G., Genet, B. & Lewis, J. (2006). A Peer-Based Assistance Program for Officers With the New York City Police Department: Report of the Effects of Sept. 11, 2001. American Journal Of Psychiatry: Official Journal Of The American Psychiatric Association, (1), 151. doi:10.1176/appi.ajp.163.1.151

Kulbarsh, P. (2016) “2015 Police Suicide Statistics” Officer.com. Retrieved on September 4, 2016 from http://www.officer.com/article/12156622/2015-police-suicide-statistics

Levenson Jr, R. L., O’Hara, A. F., & Clark Sr, R. (2010). The Badge of Life Psychological Survival for Police Officers Program. International Journal Of Emergency Mental Health & Human Resilience, 12(2), 95-101.

Mishara, B. L., & Martin, N. (2012). Effects of a comprehensive police suicide prevention program. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(3), 162-168. doi:10.1027/0227-5910/a000125

New Jersey Police Training Commission. (2016) Basic Course for Police Officers.

Roufa, T. (2015) “What is the Divorce Rate for Police Officers?” The Balance. Retrieved on September 4, 2016 from https://www.thebalance.com/what-is-the-divorce-rate-for-police-officers-974539

Stedman, T. (2016) Stedman’s Medical Dictionary (28th ed.). Philadelphia: Lippincott Williams & Wilkins.

Cite this article as: MacDonald, D.K., (2016), "Law Enforcement Suicide Prevention," retrieved on October 25, 2016 from http://dustinkmacdonald.com/law-enforcement-suicide-prevention/.
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Understanding Child Sexual Abuse


Childhood sexual abuse is one of the most harmful experiences an individual can go through in their entire life. Often covered up and denied, by both the offender, and society at large, we’ve made great strides in exposing these wounds to the light and developing better treatments for those who have experienced this suffering.

This article reviews a number of elements in the understanding and treatment of child sexual abuse. Because most of the resources on sexual abuse examine women exclusively or primarily, they will be the focus of this article. I hope to write one on male survivors of sexual abuse soon.

Defining Child Sexual Abuse

The World Health Organization (WHO) defines child sexual abuse as “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violate the laws or social taboos of society” (WHO, 2006)

Prevalence of Child Sexual Abuse

In Canada, the rate of sexual assault of those under 18 is approximately 201 per 100,000 (Statistics Canada, 2008), while an Ontario study identified approximately 13% of females and 5% of males had reported sexual abuse. (MacMillan, et. al., 1997) US studies began in the 1950s and reported between 20 and 30% of men and women reported sexual contact with children. (Draucker & Martsolf, 2006; p. 2)

Impact of Child Sexual Abuse

Child sexual abuse has been associated with life-long emotional health challenges including “the development of a range of psychiatric difficulties, including depression…self-harm…anxiety disorders…and post-traumatic stress disorder” (Barrera, Calderon & Bell, 2013) Other negative impacts can include substance abuse (Sartor, et. al., 2013) and risky sexual behaviour. (Roemmele, & Messman-Moore, 2011)

As well, survivors of childhood sexual abuse are also at greater risk for developing physical health issues, with Moeller et. al. (1993) reporting that women who were abused reported “significantly more hospitalizations for illnesses, a greater number of physical and psychological problems, and lower ratings of their overall health” than non-abused women.

False and Recovered Memories

There is a controversy in the treatment of survivors of sexual abuse about the potential for recovered memories, “the recall of traumatic events not previously remembered” (Draucker & Martsolf, 2006; p. 15) and false memories, allegedly implanted by the therapist using improper or even fraudulent techniques.

The general scientific consensus (e.g. as summed up by Ilsley (1998) is that while false memories can occur, they are the exception rather than the rule. Therefore care must be taken to avoid introducing these memories, but survivors of sexual abuse should be believed in the absence of information suggesting otherwise. This does not mean that criminal prosecution should adopt a different standard (indeed, many individuals who receive treatment for sexual abuse could never secure convictions) but merely that the potential for false memories should not dissuade a therapist from providing treatment.

The research is continuing and therefore counsellors should keep themselves informed on the latest developments in this area.

Phase Model for Treatment of Child Sexual Abuse

A phase-based model is a method of treating childhood sexual abuse that is focused on multiple distinct stages of the treatment, with specific goals for each stage. The following example of phase-treatment comes from Courtois (2004):

Phase 1

The goals of phase 1 are to explore the client’s motivation to get better, ensure informed consent (including the client’s rights and responsibilities), and educating the client on what psychotherapy is. This is also the time to establish an effective therapeutic alliance with the client, so that they can ensure the most success.

As Courtois notes, phase 1 doesn’t look much different from other forms of psychotherapy, though it may take much longer to establish in sexual abuse than other presenting problems. The acronym RICH is used as a short-hand for the four goals of phase 1:

  • Respect
  • Information
  • Connection
  • Hope

Building life skills is also a significant component of phase 1. These skills can include techniques like deep breathing, communicating one’s needs, identifying one’s emotional state, coping skills, and a variety of others that may depend on the specific client deficits.

Phase 2

The goals of phase 2 are to begin the process of developing an integrated understanding of the abuse. The client begins to construct a narrative to objectively describe the abuse in terms of the who, what, where, why, and their own reactions to the experience.

Desensitization through graduated exposure therapy is used to help reduce the impact of dissociation and allow the client to separate themselves from the abuse experience. This has been found to be an effective way of increasing the client’s ability to control their emotional regulation and decrease other symptoms. (Cloitre, 2002)

Phase 3

The final phase involves fine-tuning the skills developed in stage 1 and begins to build a new life post-abuse. At this point the client can begin tackling elements typical or a more normal range of experiences including “the development of trustworthy relationships and intimacy, sexual functioning, parenting, career and other life decisions, ongoing decisions/ discussions with abusive others, and so forth.” (Courtois, 2004)

Implications for Crisis Intervention

Helpline callers or chat and text visitor may disclosure historical sexual abuse to you. If they do, there are some things you should keep in mind to respond most effectively:

  • Check for immediate safety if it is not clear the abuse was in the past – this is especially important in a situation where the person is still young
  • Adopt a supportive tone without gawking or getting shocked. This can further stigmatize the individual and heighten their sense of isolation
  • Consider supportive responses as noted by Draucker & Martsolf (2006; p. 44):
    • Acknowledging the difficult step of disclosing
    • Offering support and indicating one’s availability after the session during which the client disclosed
    • Inviting the client to discuss the abuse at his or her own pace
    • Evaluating the client’s mental status and determining any immediate safety concerns (e.g. suicidal thoughts)
  • On the phone, watch for symptoms of dissociation or Dissociative Identity Disorder (DID)
    • If the individual starts to dissociate, try a grounding exercise: have them identify things they can see, hear (including your voice), or smell in the room. This will help them stay focused
    • If a person appears to switch personalities, remain calm but do not breach confidentiality. Treat the second personality as another person but work to get them medical assistance as soon as possible

Additional Resources

The free e-course “Addressing Past Sexual Assault in Clinical Settings” is provided by Women’s College Hospital in Toronto and funded by the Government of Ontario.

The book Counselling Survivors of Childhood Sexual Abuse provides a comprehensive review of the assessment and treatment of sexual abuse in children.

The office of Juvenile Justice and Deliquency Prevention hosted a webinar titled “Male Survivors of Sexual Abuse” which will hopefully be available on their website for viewing soon.


Barrera, M., Calderón, L., & Bell, V. (2013). The Cognitive Impact of Sexual Abuse and PTSD in Children: A Neuropsychological Study. Journal Of Child Sexual Abuse, 22(6), 625-638. doi:10.1080/10538712.2013.811141

Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal Of Consulting And Clinical Psychology, 70(5), 1067-1074. doi:10.1037/0022-006X.70.5.1067

Courtois, C.A. (2004) Complex Trauma, Complex Reactions: Assessment and Treatment. Psychotherapy. 41(4) 214-425. DOI 10.1037/0033-3204.41.4.412. Retrieved on October 8, 2016 from http://www.dhss.delaware.gov/dsamh/files/si10_1396_article1.pdf

Draucker, C.B. & Martsolf, D.S. (2006) Counselling Survivors of Childhood Sexual Abuse. 3rd Ed. London: SAGE Publications.

Ilsley, J. K. (1998). Recovered memories of childhood abuse : We must tell patients that they were not to blame. BMJ : British Medical Journal, 317(7164), 1012.

MacMillan, H.L., Fleming, J.E., Trocme, N., Boyle, M.H., Wong, M., Racine, Y.A., Bearslee, W.R. & Offord, D.R. (1997) JAMA. Prevalence of Child Physical and Sexual Abuse in the Community. 278(2). 131-135

Moeller, T. P., Bachmann, G. A., & Moeller, J. R. (1993). The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women. Child Abuse And Neglect, (5), 623.

Roemmele, M., & Messman-Moore, T. L. (2011). Child Abuse, Early Maladaptive Schemas, and Risky Sexual Behavior in College Women.Journal Of Child Sexual Abuse, 20(3), 264-283. doi:10.1080/10538712.2011.575445

Sartor, C. E., Waldron, M., Duncan, A. E., Grant, J. D., McCutcheon, V. V., Nelson, E. C., & Heath, A. C. (2013). Childhood sexual abuse and early substance use in adolescent girls: the role of familial influences. Addiction, 108(5), 993-1000. doi:10.1111/add.12115

Statistics Canada. (2008) Child and Youth Victims of Police-reported Violent Crime, 2008. Retrieved on October 8, 2016 from http://www.statcan.gc.ca/pub/85f0033m/2010023/part-partie1-eng.htm

World Health Organisation (WHO). (2006) Preventing child maltreatment: a guide to taking and generating evidence. Retrieved on October 8, 2016 from http://apps.who.int/iris/bitstream/10665/43499/1/9241594365_eng.pdf. Geneva: World Health Organisation (WHO).

Cite this article as: MacDonald, D.K., (2016), "Understanding Child Sexual Abuse," retrieved on October 25, 2016 from http://dustinkmacdonald.com/understanding-child-sexual-abuse/.
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Cognitive Behavioral Analysis System of Psychotherapy (CBASP)


CBASP is a form of psychotherapy first described in 1984 by James McCullough and expanded on in his full-length book Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP) published in 2000. Although its name sounds similar, it should not be confused with Cognitive Behavioural Therapy (CBT) or similar forms of therapy.

The goal of CBASP is to “teach the patient to focus on the consequences of behaviour, and to use problem solving to resolve interpersonal difficulties. (Driscoll, et. al., 2004, pg. 2)

A 2016 meta-review confirmed that CBASP is effective for the treatment of major depressive disorder, especially when combined with medication. (Negt, et. al., 2016), while a comparison of CBASP versus treatment-as-useful — other evidence-based therapies for depression — in Wiersma et. al. (2014) found that CBASP was at least as effective as the other treatments from 8 weeks up to 32 weeks but performed better by 52 weeks, suggesting it kept clients better, for longer.

Principles of CBASP

McCullough believes that depression is caused by “learned Pavlovian fears of interpersonal encounters, and maintained by a refractory pattern of Skinnerian interpersonal avoidance.” (McCullough, 2006) Essentially what this means is that clients develop a fear of relationships based on previous bad experiences that leads them to isolation and a disconnect from their environment.

CBASP involves the client completing paperwork called the Coping Survey Questionnaire (CSQ) in between each session. These CSQ forms are used to document stressful or challenging interactions with other people by exploring what happened, how the client reacted, and what the client wanted to happen. Then the CSQs are reviewed in therapy in a process known as Situational Analysis (SA).

According to Driscoll, et. al., (2004, pg. 4) analyzing one CSQ will likely take a full session in the beginning of treatment, but as a client masters the elements of the CSQ and the SA steps (described in more detail below) they will find themselves able to cover several CSQs in one session.

Coping Survey Questionnaire (CSQ) for use in CBASP

Five Steps of Situational Analysis

The five steps of Situational Analysis mirror the items on the CSQ.

Step 1. Describe the situation

In the first step, the client is expected to describe in 3 to 4 paragraphs a specific situation that occurred without editorializing or providing extraneous detail. The goal is for the therapist to be able to understand all of the interactions that occurred in that single instance.

Step 2. State interpretation

In step 2, the client provides their interpretations about what occurred during that conversation. Many times clients will make interpretations that are broad, based on situations that are very specific. For instance, a client who receives poor customer service from a cashier may state, “He wasn’t nice to me because I’m ugly.” Asking the client to provide two or three thoughts that occurred during the interaction, or asking the client what the situation meant to them in the moment may help spur the production of interpretations.

The most effective interpretations are those that lead to the desired outcome (DO), what the client wished had happened in that situation had it occurred again.

Step 3. Identify reactions

In step 3, the client records all of their own behaviours and reactions. These include voice tone, body language, pace, and other reactions the client may have had like walking away from the situation. This allows the client to identify avenues for changing behaviours to more easily reach the desired outcome.

Step 4. Explain the desired outcome (DO)

In step 4, the client explains the Desired Outcome (DO). The therapist can ask, “What were you trying to get out of this situation?” or “How did you want things to go” in order to spur this part of the conversation. One DO should be produced for each CSQ that is completed. These DOs should be SMART (specific, measurable, attainable, realistic and timely.)

One important element related to DOs is that they have to involve the client themselves. A DO can’t involve change in another person because we don’t have control over that person. What the client does have control over is their own reactions and responses.

Step 5. Illustrate the actual outcome (AO)

The actual outcome (AO) is perhaps the easiest step, because this explores what the client actually got out of the experience. Usually this is a negative experience but it doesn’t have to be — a positive AO may be an opportunity for the client to identify what went right and how they can repeat this in the future.

After Situational Analysis

After the SA phase is complete, the client has explained the situation, what happened, how they reacted, what they wanted to happen, and how the situation ended. This is known as the elicitation phase. The next stage of the two-part process is the remediation phase.

In the remediation phase of CBASP, the interpretations and behaviours are looked at to figure out if they’re the most useful beliefs or effective responses to the situation. If they’re not (and many times they aren’t), more effective interpretations and behaviours are suggested in order to help the client better reach the DO.


Driscoll, K.A., Cukrowicz, K.C., Reardon, M.L. & Joiner, T.E. (2004) Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy. Mahwah, N.J.: Lawrence Elbaum Publishers

McCullough, J. P. (1984). Cognitive-behavioral analysis system of psychotherapy: An interactional treatment approach for dysthymic disorder. Psychiatry: Journal For The Study Of Interpersonal Processes, 47(3), 234-250.

McCullough, J. P. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy. New York, NY: Guilford.

McCullough, J. P. (2006). Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP). New York, NY: Springer.

Negt, P., Brakemeier, E., Michalak, J., Winter, L., Bleich, S., & Kahl, K. G. (2016). The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials. Brain And Behavior, (8), doi:10.1002/brb3.486

Wiersma, J.E., Van Schaik, D.J., Hoogendorn, A.W., Dekker, J.J., Van, H.L., Schoevers, R.A., Blom, M.B., Maas, K., Smit, J.H., McCullough, J.P., Beekman, A.T. & Van Oppen, P. (2014) The effectiveness of the cognitive behavioral analysis system of psychotherapy for chronic depression: a randomized controlled trial. Psychotherapy and Psychosomatics. 83(5): 263-9. doi: 10.1159/000360795

Cite this article as: MacDonald, D.K., (2016), "Cognitive Behavioral Analysis System of Psychotherapy (CBASP)," retrieved on October 25, 2016 from http://dustinkmacdonald.com/cognitive-behavioral-analysis-system-psychotherapy-cbasp/.

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How to Perform Social Return on Investment


Social Return on Investment (SROI) is a way of measuring the impact of projects or programs that is especially suited to the work that non-profits do. To see the difference, let’s move from a for-profit to a non-profit mindset. A for-profit’s return on investment (ROI) focuses on money only: for instance, $25,000 investment in supply chain management results in an additional $75,000 in revenue; this means the ROI is 3:1, or $50,000.

Because non-profits don’t often generate revenue, this measure is less useful. Instead, non-profits often track outcomes like the number of clients served. At the Distress Centre, we receive over 7500 calls a year and save approximately 35 lives through emergency intervention. These numbers are useful, but they don’t translate well into a per-dollar figure. For instance, on a budget of $260,000 (a rough estimate), we pay $35 per call, or $7,429 per emergency intervention.

Is $35 per call reasonable? It may appear to be too expensive. What about when we divert an individual from hospital, or prevent a suicide attempt in progress? We have no way to track the monetary benefits of these, until we use SROI.

How SROI Works

SROI works by assigning a monetary value to activities that until now could not be monetized. Some of these are easier to calculate because real dollars are involved (for instance, when you de-escalate someone and they don’t need to go to the hospital, you’ve saved the cost of the police/ambulance and the emergency room service), while some are more difficult (the increased quality of life that one gets from a conversation on a crisis line.)

Value is assigned by a variety of methods that try best to approximate the costs involved. These items that are used to approximate value are called “proxies”, and lists of proxies are available on SROI-related websites.

Performing SROI

SROI has six major steps:

  1. Establish the scope and identify stakeholders
  2. Mapping outcomes
  3. Demonstrating outcomes and giving them a value
  4. Establishing impact
  5. Calculating the SROI
  6. Reporting, using and embedding

These are reviewed in more detail below. The data (charts, financial proxies, explanations, etc.) is reproduced from an unpublished SROI analysis conducted by myself, of the ONTX Chat and Text Program at Distress Centre Durham.

Establish the Scope and Identify Stakeholders

Establishing the scope for an SROI analysis involves identifying the purpose, audience and focus of the analysis. 

The audience for this analysis includes the four pilot Centres, our funding partners (Trillium, United Way and Greenshield Canada) and other services interested in producing a similar analysis of their service. The focus will be on one year of outcomes data collected in the operation of the ONTX project.

Stakeholders, in the SROI methodology, are individuals who experience gains as a result of the service provided. These can be direct gains (such as the reduction in distress experienced by a visitor to the crisis chat service or the savings experienced by not having to use EMS resources transporting a suicidal person to hospital) or indirect gains (such as the career benefits experienced by a responder who delivers the service or the of improved relationships with friends and family visitors may experience.)

In order for stakeholders to be included in the analysis, they must be material – that is, they must experience a benefit as a result of the service.

Mapping Outcomes / The Theory of Change

A theory of change, also known as a logic model, is a cornerstone of the SROI methodology that describes how inputs (the funds and people used in direct service delivery) result in changes (outcomes) that can be quantified to value the service. An example logic model for the ONTX Chat and Text Program is listed below:

Stakeholder Intermediate Outcomes Final Outcome
  • Decreased harmful intentions
  • Immediate crisis diffused
  • Decreased suicidal intent
Reduced likelihood of visitor attempting suicide
  • Improved self-esteem, self-control or confidence
  • Less distressed or anxious
  • Options explored
  • Action plan explored
Improved visitor coping skills
  • Decreased isolation and loneliness
  • Improved connectedness
  • Knowing a responder is there for them
Enhanced visitor belonging
Police / EMS
  • Less likely to require ambulance or police service because of a high-risk suicidal caller
Reduced use of 911
  • Fewer responses to suicide deaths because of Responder intervention
Reduced cost to 911/EMS
Medical System
  • Less instances of hospital admission because of self-harm/suicide attempts
Reduced use of public health system

Demonstrating Outcomes and Giving Them a Value

Each of the final outcomes from the chart above needs to be operationalized, which involves identifying concrete elements to suggest an outcome has or will occur. This allows an assignment of financial value to those outcomes in determining the SROI.

Each of the above outcomes requires a financial proxy, or a method of quantifying its value. Some financial proxies are simple unit costs, like the cost of deploying police and an ambulance to respond to a suicidal crisis, while others are more difficult to quantify.

In consultation with stakeholders, a review of the SROI literature (including with other crisis chat services), the following financial proxies were decided upon:

Final Outcome Financial Proxy Calculation (all figures in dollars unless noted) Value per Instance
Reduced Likelihood of Visitors Attempting Suicide One month of life, adjusted with the disability weight assigned to Suicide and Self Harm (Value of a Statistical Life Year (VSLY) / 12 months) x 0.64 weighting $6,900.49
Improved Visitors Coping Skills Cost of two visits to a family doctor/general practitioner 40 per visit x 2 $80
Enhanced Visitor Belonging One week of leisure for the median Canadian income 3922 (yearly leisure expenses) / 52 $75.42
Reduced Cost of 911/EMS Cost of ambulance response for a suicide attempt 600 $600
Reduced Cost of Police Response to Suicide Death Unit cost of two police officers and two paramedics responding for total of 5 hours at median wage 36.53 x 2 x 2 (Police)

25.81 x 2 x 1 (Paramedic)

Reduced Use of Public Health System Cost of hospitalization for suicide attempt minus the average cost of an ED visit (998 x 7.74) – 267 – 249.36 $7,208.16

Establishing Impact

The SROI methodology involves totaling the number of outcomes (now quantified as dollar values) against the total cost of inputs required to operate the service. Inputs can include direct service, such as employees, technology costs, advertising and so on.

Because three of the four Centres did not receive funding to hire an independent staff person, a value of 25% on a salary of $40,000 was used. This provides an estimation of the dollar value.

Input Description Value ($)
Distress Centre Durham Staff (prorated to 8 mos.) $15,000 x 0.8333 = $12,500
ONTX Grant (pro-rated to 6 mos.) $257,700 / 4 = $64,425
Community Torchlight Staff (est.) $10,000
Distress Centre Toronto Staff (est.) $10,000
Spectra Helpline (est.) $10,000
Total Inputs $106,925

Number and Dollar Value of Final Outcomes

Based on one year of data (June 29 2015 to June 29 2016), we can see the following outcomes. Only the items directly from the call reports are reported below for this sample analysis. The other intermediate outcomes (such as Less likely to require ambulance or police service because of a high-risk suicidal caller) have been operationalized in the report but are not listed here for space and complexity reasons.

Reduced Likelihood of Visitor Attempting Suicide ($6900.49 x 1,190)

Decreased harmful intentions – 522
Immediate crisis diffused – 301
Decreased suicidal intent – 367

Improved Visitor Coping Skills ($80 x 3,794)

Improved self-esteem, self-control or confidence – 796
Less distressed or anxious – 1831
Action plan explored – 1167

Enhanced Visitor Belonging ($75.42 x 1473)

Decreased isolation and loneliness – 1473


$6900.49 x 1,190
$80 x 3,794
$75.42 x 1473
= $8,626,196.76

Deadweight and Attribution

Next, we have to estimate deadweight and attribution. Deadweight is the percentage of the outcome that would have happened regardless of our involvement. For instance, if a visitor told us that if they couldn’t reach our service, they knew five others they could, it is unlikely that much of the outcome would be lost if they could not access the ONTX pilot.

We have decided to calculate deadweight as a 15% reduction in overall value for every resource a visitor could identify as an alternative to our service. Since the average was 2, we assume 30% in deadweight.

Attribution is the amount of the benefit that is attributed to other persons. Because our service is often the primary intervention we have limited attribution, so for this analysis we will not note any attribution.

This takes our benefit value of $8,626,196,76 and reduces it to $6,038,337.732.

Finishing our Calculation

We take our total benefits generated, divide them by the total cost of the input to find the SROI ratio.

$6,038,337.732 Total Benefit / $106,925 Total Inputs = SROI Ratio of $56.47

For every one dollar invested in the ONTX pilot there is a social benefit of $56.47.

Sensitivity Analysis

Sensitivity analysis is a way of repeating calculations to take into account higher or lower than expected figures. See the table below:

Final Outcome Low Financial Proxy Original Financial Proxy High Financial Proxy Low Value Moderate Value (used for analysis) High Value
Reduced Likelihood of Visitors Attempting Suicide One week of life, adjusted with the disability weight assigned to Suicide and Self Harm One month of life, adjusted with the disability weight assigned to Suicide and Self Harm Two months of life, adjusted with the disability weight assigned to Suicide and Self Harm 1,592.42 6,900.49 13,800.98
Improved Visitors Coping Skills Cost of one visits to a family doctor/general practitioner Cost of two visits to a family doctor/general practitioner Cost of four visits to a family doctor/general practitioner 40 80 160
Enhanced Visitor Belonging One day of leisure for the median Canadian income One week of leisure for the median Canadian income One month of leisure for the median Canadian income 10.75 75.42 301.68
Reduced Cost of 911/EMS N/A Cost of ambulance response for a suicide attempt N/A 600 600 600
Reduced Cost of Police Response to Suicide Death Unit cost of two police officers and two paramedics responding for total of 2 hours at median wage Unit cost of two police officers and two paramedics responding for total of 5 hours at median wage Unit cost of two police officers and two paramedics responding for total of 7 hours at median wage 99.74 249.36 349.10
Reduced Use of Public Health System Cost of hospitalization for 3 days minus the average cost of an ED visit Cost of hospitalization for suicide attempt minus the average cost of an ED visit Cost of hospitalization for 12 days minus the average cost of an ED visit 2,477.64 7,208.16 11,339.64

Based on the low and high values specified we have benefits as follows. The reason we multiply by 0.7 is our deadweight, estimated earlier.

1,894,978.8 + 3200 + 15834.75 = 1,914,013.55 x 0.70 = 1,339,809.485

16,423,166.2 + 607,040 + 444,374.64 = 17,474,580.84 x 0.70 = 12,232,206.588

Returning to our original formula:

  • Low $1,339,809.485 Total Benefit / $106,925 Total Inputs = SROI Ratio of $12.53
  • Moderate (already calculated) $6,038,337.732 / $106,925 Total Inputs = SROI Ratio of $56.47
  • High $12,232,206.588 Total Benefit / $106,925 Total Inputs = SROI Ratio of $114.40

Therefore our SROI analysis ranges from $12.53 – 114.40. Given this wide range, it may be safer to use a value of +/- 15% of our middle value, or to explore more carefully the value of the Final Outcome Reduced Likelihood of Visitors Attempting Suicide (which is currently calculated in terms of months of life, adjusted with the disability weight assigned to Suicide and Self Harm.)

Cite this article as: MacDonald, D.K., (2016), "How to Perform Social Return on Investment," retrieved on October 25, 2016 from http://dustinkmacdonald.com/perform-social-return-investment/.
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