Advances in Suicide Assessment and Treatment Planning with Youth

1. Advances in Suicide Assessment and Treatment Planning with Youth Presented in Collaboration with the Bitterroot Valley Educational Cooperative and Big Sky Youth Empowerment Program John Sommers-Flanagan, Ph.D., University of Montana Department of Counselor Education John.sf@mso.umt.edu or johnsommersflanagan.com

2. Preparation • Emotionally challenging topic: Trigger warning • Opening stories – Hospitals, TCJC, and Yours • BIG learning goal – Prepare to work with suicidal clients with courage and humility. • Questionnaires/quizzes!

3. Learning Strategy • Fill out informed consent for research (optional) • Complete part one of research packet (15-20 min) • Participate and learn today • Complete part two of research packet (20 min), to help with learning consolidation • Sign up to participate in optional 3 or 4 month follow-up • Continue learning independently and together

4. CaveatS and Disclaimers • The American Association of Suicidology (AAS) has 24 competencies under eight domains • Granello wrote of 25 strategies and 12 principles • Jobes, Joiner, Shneidman, Maris, Linehan, etc. • New learning will continue . . . forever . . .

5. Caveats and Disclaimers • My youngest daughter is an attorney • The information provided today is based on research and clinical wisdom. I hope it will help you in your work. • As professionals, you’re responsible for the application of this and other educational and training experiences into your work. • By attending today, you agree you will not hold the presenter responsible for any adverse outcomes that might be associated with this course material.

6. Learning Objectives • Develop greater self-awareness and a more positive attitude toward working with youth (and parents) who are suicidal.

7. Learning Objectives • Build your suicide knowledge • Practice suicide assessment, intervention, and treatment planning skills

8. Our Ground Rules • Be open to learning • Communicate respectfully • Engage in experiential activities to whatever extent you can • Take care of yourself as we learn together (6.5 hours) and beyond

9. And Remember • This is YOUR workshop • Your input and comments are welcome, not mandatory (I will keep us on track – more or less)

10. Clinician Attitude • Suicide is probably the biggest stressor that we face • Anxiety and irritation [waste of time] • Practice is essential, but learning and practicing is triggering • What are your reactions to and BELIEFS about suicide?

11. Activity – Awareness • Let’s imagine a scenario • You’re doing counseling • You need to ask about suicide • Tommie, 18 y/o Yupik tribe – 14:14 to 15:15 • https://players.brightcove.net/624142947001/r1evdKsni_default/index.html?videoId=5095441194001

12. Practice Activity – Reflections • Talk with your neighbor about youth suicide disclosures: • What do you feel in your body, and where • What thoughts and emotions do you experience? • What helps you cope?

13. Clinician Attitude • We WANT students to disclose suicide ideation. Why? • We cannot help, if we do not know • YOU have skills to help clients deal with SI • And so we convey confidence, competence, and comfort with this important issue • SI is PRIMARILY a communication of distress (not MI or deviance, mostly not attention-seeking) • SI isn’t a good predictor of suicide • Set aside all of our moral and philosophical quirks

14. Clinician Knowledge: Myth Busting

15. A Strength-Based Model • We believe deeply in acceptance, in acknowledging pain, and in not pathologizing; we collaborate; we intentionally focus on strengths and balance our assessment and counseling questions.

16. Research and Practice Organization • Emotional [Core: Excruciating distress] • Cognitive or Mental [Mental constriction, “nothing helps”] • Interpersonal [Social disconnection or perceived burden] • Physical/Biomedical [Agitated, impulsive, ill, and drugs] • Spiritual/Cultural [Meaninglessness or disconnection] • Behavioral [Suicide plan/intent, lethal means available]

17. Back to Risk/Protective FActors • Risk/protective factors don’t work for prediction; they work for understanding individuals . . . BUT • We may work in a setting that requires risk categorization • We may need to involuntarily hospitalize • Still proceed as collaboratively as possible

18. Risk or protection? • Cutting? • SSRIs? – Black box warning! • Unemployment or no school? • Family separation? • Others?

19. Categorizing Risk • We may need to do this (but don’t fool yourself) • None:No risk and no need for suicide in treatment plan • Mild: Minimal risk. Managed with weekly monitoring and an emergency plan. Make sure firearms and lethal means are safely stored. • Moderate: Manage with an active safety plan. Engaging family/friends may be advisable. Make sure firearms and lethal means are safely stored. • High: Treatment will be hospitalization and/or an intensive safety plan implemented with family/friends. Firearms and lethal means are safely stored.

20. Risk Assessment Rules (Handout) • Risk Factors and Warning Signs: Generally, more risk factors and warning signs equals more risk. Factors that are particularly salient include: • 2+ previous attempts • Command hallucinations (e.g., “You must die”) • Trauma • Severe depression, plus agitation and hopelessness • Preparation, planning, rehearsal behaviors (e.g., stockpile, giving away items) • Feeling trapped in immense shame, self-hatred, and excruciating distress • Protective Factors: Relationships, hope, engagement in meaningful activities, responsiveness to therapy/treatment • Consultation: Isolation can be contagious; don’t isolate yourself • Documentation: Include relevant assessment data, consultation results, and rationale for decision-making [on risk categorization and level of care].

21. Categorizing Risk II • Use checklists if you must • But, gold standard = collaborative clinical interview: • Psychoed: We know it’s not good to be alone with SI • SPI: Will you work with me (or someone)? • If no engagement, risk increases

22. Our Destination

23. Case – Kennedy – Opening • Kennedy is a 15-year-old referred by her parents for depression/suicide ideation [Simulation] • This is session #1: 1:38 – 5:04 • Watch for: (a) first mention of suicide; (b) first focus; (c) problem-solving; (d) “gun” mention; (e) the domains

24. Assessment: Process and skills First step: Asking about (or acknowledging) suicide ideation • Use a normalizing frame • Use gentle assumption • Use mood scaling with a suicide floor • Use balanced questioning

25. Skill 1: Normalizing Frame • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you? • Most people who feel down think about suicide from time to time. Have you had thoughts about suicide? • Practice these or similar words

26. Skill 2: Gentle Assumption • Don’t ask: “Have you thought about suicide?” • Instead ask: “When was the last time you thought about suicide?” • Especially for use in emergency settings (Shea)

27. Skill 3: Mood Scaling • May I ask some questions about your mood? • Demo • Practice

28. Mood scaling Practice • Rate your mood, using a zero to 10 scale. Zero is the worst mood possible. Zero means you’re totally depressed and so you’re just going to kill yourself. A 10 is your best possible mood. A 10 would mean you’re as happy as you could be, maybe dancing or singing or doing whatever you do when you’re extremely happy. Using zero to 10, what rating would you give your mood right now? • What’s happening now that makes you give your mood that rating? • What’s the worst or lowest mood rating you’ve ever had? What was happening to make you feel so down? • For you, what would be a normal mood rating on a normal day? • What’s the best mood rating you’ve ever had? What was happening that helped you have such a high mood rating?

29. Mood scaling – reflections Be with your supportive neighbors and discuss: • What thoughts and feelings did the mood rating bring up for you? • What problems did you feel/encounter? • How might you use it (variations)?

30. Problems with Scaling • The scale is more subjective than objective • A 3 for me may not equal a 3 for you • A 9 may be linked to suicide ideation • Try to ground the scale deep in your clients’ experiences • Focus on what triggers downward AND upward movement [with or without numbers]

31. Kennedy – Mood scaling Skill Demo of Mood Scaling with a Suicide Floor 13:37 – 17:07 Empathically validate and normalize!

32. Kennedy – Discussion • What did you learn about Kennedy? [Let’s look at our Treatment Planning Handout] • I went back to problem-solving – why? • PS is BOTH . . . And . . . • Primary thinking impairment = Overly narrow thinking (constriction). Suicide or misery

33. What Did We Learn About Kennedy?

34. Excruciating Distress is primary

35. Skill 4: Strength-Focused Questioning • Don’t just ask about depression and risk. [??] • Ask about protective factors and strengths • What has helped before? • Hopes for today, tomorrow, etc. • When is your sadness gone? • What helps you concentrate, sleep? • What brings a little light into the darkness?

36. Emotional Main Treatment Planning Targets • Excruciating Distress • Affect dysregulation • Acute or chronic shame/guilt/sadness

37. Emotional: Separate pain From self • Role Play with notepad • Debrief – What are the therapeutic benefits and liabilities of this intervention? • Battling Excruciating Distress

38. NeoDissociation Skill • JSF Story • Debrief – There are nearly always dissenting parts of the self. How do we activate them and use them therapeutically?

39. Emotional: Affect Regulation • Mindfulness • Distress tolerance: Just Breathe • Three-step emotional change trick [Role Play]

40. Cognitive Main Treatment Planning Targets • Problem-Solving Impairment • Hopelessness • Negative Core Beliefs

41. Alternatives to Suicide Skill • Shneidman Story • Kay Clips: 1:50:02:23 – 2:00:28:06 or Role Play?

42. Hopelessness Role Play • Volunteer Needed! • JSF First

43. Hopelessness protocol • Hopelessness Reflection: “I hear you saying that, right now, you feel completely miserable and hopeless” • Match Language and Explore: “Do you mind telling me more about what’s feeling shitty right now?” • Validate: “It’s natural . . .” • Start From the Bottom: “What makes it worst?”

44. Negative Core Beliefs • Mark them using “Carl Rogers with a Twist” • “Sometimes the way you talk makes me think you think there’s something wrong with you.” • Explore, and bookmark for later [CBT].

45. Interpersonal [Social] Main Treatment Planning Targets • Unwanted Social Disconnection • SocialSkill Deficits • Social Burden

46. Social Universe mapping skill • Role play or video? • Chase described two toxic people in his life • Show Chase Clip 1:15:23 - 1:20:01 then 1:21:45 – 1:24:34

47. social Universe Skill • How might you use this social universe assessment therapeutically? • Build a continuum from the bottom up • What does John do poorly at the end?

48. Simple social Questions • What would your best friend say/do? • Who feels comfortable? • Who would you call if stuck out, late, and needed help? • Skills training! Keb Mo

49. Physical Main Treatment Planning Targets • Arousal/Agitation/Irritability • Physical symptoms of depression

50. Physical: Irritability Role Play • Volunteer Needed! • JSF first • Cutting variation – “I’m not stopping!”