challenging Students : Suicide Assessment and Management

1. challenging Students: Suicide Assessment and Management John Sommers-Flanagan, Ph.D. University of Montana Email: John.sf@mso.umt.edu Blog: johnsommersflanagan.com Presented on Behalf of Vancouver School District #37 - August 23, 2017

2. Workshop Overview • This workshop is rated “R” • It’s a blend of theory, clinical experience, and evidence-based material (relational and technical) • Caveats and excuses • Working with youth is not a perfectly linear process – and neither is this workshop

3. Workshop Overview -- II • We’ll do this in four parts 1. Principles and techniques (the fun part) 2. Suicide information 3. Suicide assessment and intervention skills 4. Exploring and improving VSD #37 protocols

4. Participation Guidelines • Input is welcome, not mandatory (TIMING) • Try to make connections with your work • Be open to new and old ideas • Communicate respectfully • It’s okay to critique what you see and hear • Have as much fun as you can while learning

5. Learner Objectives • Describe principles for working with challenging students • Apply several techniques for influencing students • Articulate contemporary issues related to suicide assessment

6. Learner Objectives • Learn specific strength-based suicide assessment and intervention strategies • Discuss and identify methods that will help you be more efficient and effective (and less stressed) when working with suicidal students

7. Working with Adolescents • 1990 – Discovery – My input not appreciated • 1997 – Clever Title: Tough Kids, Cool Counseling • But who are the “Tough Kids” • Imagery activity • 30 Minutes of Profanity

8. No More Tough Kids • Only so-called tough kids • Only kids in tough situations • And counseling is one of those • The invisible antenna • Thinking that way leaks through

9. Evidence-Based Principles • Use radical acceptance, radical respect, and radical interest (reframe tough kids) • Be transparent (genuine) and non-threatening • Use counter-conditioning mojo (stimuli) • Offer collaboration

10. Time for Techniques • The principles are woven into the techniques • The WHOLE point of using techniques is to: Build relationship (and teach) • The WHOLE point of building relationship is to: Have a positive influence (and teach)

11. Top Techniques [see handout supplement] 1. Acknowledging Reality 2. Sharing Referral Information Students need to know what you know about them Counselor Behavioral Examples: • Share referral information • Educate referral sources • Describe other realities?

12. Top Techniques 3. The Authentic Purpose Statement Students need to hear your reason for being in the room. Make this statement brief and clear. Counselor Behavioral Examples: • “My goals are your goals. . .” • “I’d love to. . .” • “I want to help you get along with your parents” • Practice what YOU want to say

13. Top Techniques 4. Wishes and Goals Principle: Goal-setting with students can be tricky. Wishes and goals can help you launch an individualized and collaborative goal-setting process. Counselor Behavioral Examples: • Three wishes • Goal-setting (and limiting) with parents/caregivers • SFBT opening: If we have a great session . . . • Miracle question

14. Top Techniques 5. What’s Good About You? Reflecting on strengths, although difficult, can be emotionally soothing and reduce attachment anxiety—it also provides informal assessment data Choices – Watch video example or practice with each other?

15. Clip: Kristen • Refers to self as a “Bitch” • Reports self-esteem and mood management problems • Watch for: • Content and process • Her reaction to positive feedback

16. Group Reflection • Did you notice? • Kristen’s main theme or content? • What MI or SFBT rules John broke? • Asking permission? [Which principle?] • The comment on the smile? [Which principle?] • How and why you might use that with your students?

17. Top Techniques 6. Asset Flooding Addressing attachment insecurity requires support; criticism can cause dysregulation Counselor Behavioral Examples • Use several psychologists/counselors/educators • Check in and debrief: “How does it feel to focus on your strengths?” • It might be too intense

18. Top Techniques 7. Generating Behavioral Alternatives Principle: Problem-solving (stage 1) can help students reduce cognitive rigidity and emotional agitation while increasing mental flexibility. Counselor Behavioral Examples • Okay. Let’s just make a list of your options.

19. Clip: Pete • Pete is angry at a boy who tried to rape his girlfriend • Watch for: • How brainstorming proceeds • Pete’s affective changes • John’s risky suggestion

20. 3 Minute Reflection Turn to your neighbor and briefly discuss: • Which of the four principles you saw/heard • John staying neutral (or trying to) • Pete’s emotional reactions • Pete’s reaction to hearing the list • “That’s a good one”

21. Top Techniques 8. Using Riddles and Games Play and playful interaction is a part of many evidence-based treatments • Volunteer demonstrations – Riddles; Tic Tac Toe; soda bottles; dollar

22. Top Techniques 9. Food and Mood Look around. Use COUNTERCONDITIONING (Jones, 1924)! Never do counseling with hungry children • Healthy snacks • Hot drinks • Sharing • What do you use?

23. Review: Principles and Techniques • What are the four principles? • What techniques do you want to remember and try out?

24. Part II: Talking about Suicide • Reactions • Rick walk out story • Please take care of yourselves and talk • DIRECTLY ABOUT SUICIDE

25. My Interest • 1991 Story • Guilt and regret • Med Model Big Myths • SI = deviance, therefore: We assess, intervene, and eliminate SI

26. Bust the Big Myth • Suicidal thoughts and gestures ARE NOT SIGNS OF DEVIANCE • About 10% of human population will attempt suicide • And 20% will struggle with SI + SP • Up to 50% of teens are bothered by suicidal thoughts

27. Practice tip 1: Normalize • NORMALIZE SI; WELCOME SI discussion • Med Model thinking is unhelpful, it creates distance, disempowers, makes student feel crazier • SI NOT a sign of deviance, but normal distress • No need to freak out; let’s talk about suicide

28. tip 2: RISK FACTORs – Not very helpful Base Rates Death by suicide is infrequent: 13/100,000 – [Highest since 1986] or 0.013% . . . Youth under 14 is 0.7/100,000 or 0.007% You can’t predict suicide based on risk factors Risk factors must be individualized (e.g., cutting)

29. Research on Risk Factors • There are 25+ and many acronyms • IS PATH WARM; SAD PERSONS SCALE • Previous attempts; Cutting • Loss of relationship; New SSRI prescription

30. Risk Factors -- Critique • There are NO GOOD RISK FACTORS (Spring) • No research indicates they can predict suicide • Don’t get hung up on these; their best use is to inform us about potential suicide dynamics [For empathy] • The math: 13.0 x 25 = 325 per 100,000 or 0.0325% or 1 of every 307 patients with MDD

31. tip 3: Balance Your questions • Don’t just ask about depression and risk. • Also ask about protective factors and strengths [DAT] • When is your sadness gone • What has helped before? • Hopes for today, tomorrow, etc. • What helps you concentrate, sleep? • What brings light into the darkness?

32. Tip 4: Use theory • ES: Psychache or intense distress • Interpersonal theory: Social disconnection, thwarted belongingness, or perceived burden • Hopelessness for positive change • Arousal or agitation • Desensitization • Problem-solving deficits [mental constriction] • Lethal means

33. Tip 5: Use an Interview Model 1. R = Suicide Risk (and protective) factors 2. I = Suicide Ideation 3. P = Suicide Plan (SLAP) 4. SC = Self-Control and agitation 5. I = Suicide Intent and reasons for living 6. P = Collab safety Planning and interventions (LM + PS Deficits) • R-I-P-SC-I-P is a (mostly) linear approach

34. 6: The MOOD RATING • Integrate RIPSCIP into a conversation that includes a normative frame and a mood assessment with a suicide floor • On a scale from 0 to 10, where 0 means you’re so depressed you’re just going to kill yourself and 10 means you’re the happiest a human could possibly be and possibly dancing or whatever you do when VERY happy, how would you rate your mood right now?

35. Mood rating demo and Role play • May I ask about your mood? • Rate your mood, using a zero to 10 scale. 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 then? • 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 then?

36. Responding to Suicide ideation • SI is good to hear • Validate and normalize • Ask: What has helped before? • Ask about frequency, triggers, duration, and intensity

37. The Suicide Plan • Maybe this is even harder to ask about • Use normalizing again • Then SLAP the plan S – Specificity of the plan L – Lethality of the plan A – Availability of the means P – Proximity of social support

38. Self-Control • Ask: What helps you be in control? • Ask: What pushes your buttons and gets you agitated? • Observe for agitation

39. Coping and Self-Care 3-Step Emotional Change Trick • Feel the feeling [Honor it] • Think a new thought or do something different • Spread the good mood

40. Suicide intent • Students may disclose that they don’t want to die by suicide • Explore RFLs • Separate the distress from the self

41. Safety Planning • When they say: “Nothing helps” build a continuum • Remember, there may be problem-solving impairments • Use a safety planning form – But first, practice using it with each other

42. practice Tip 7: Safety planning • There’s no substitute for the safety plan • This involves collaborative work on identifying individual warning signs, coping responses, social distractions, support networks, and environmental safety (e.g., firearms) • It flows from the “Mood assessment protocol”

43. Safety Planning • How Can I Make My Environment Safe? • My Unique Warning Signs • My internal Coping Strategies • People and Settings that Provide Support and Distraction • Who Can I Ask for Help? • Professionals or Agencies I Can Contact for Support • How I Can Make My Environment Even Safer?

44. Safety Planning • I want you to live • But I know it’s your choice to live or die • Most people feel better after 3-4 months of counseling • Why not give it a try, you can always choose to die later • [Mostly adapted from Jobes, 2016]

45. Practice • “Nothing works” – Building a continuum • Safety planning form

46. Decision-Making • You can screen with an instrument, but you must do face-to-face follow-up with every positive screen • If you use the 0-10 rating interview, someone will need to follow-up or continue, when needed, with safety planning • What does “When needed” mean?

47. Decision-Making II • When needed: • Is subjective [trust your professional staff and the rule of 3] • Consider Distress + Social Factors + Hopelessness + Problem-Solving Deficits + Agitation + Desensitization + Lethal Means • Go with a collaborative plan as possible • Contact parents or guardians, restrict lethal means, intervene on the other six factors listed above and any idiosyncratic factors as well • Always consult • Document everything, but not primarily as self-protection

48. PRoblems • Scaling is subjective • Going up or going down are both risks • Need to use the student’s language [a “down” mood] • Immediate crises

49. Brief Suicide Interventions • No suicide contracts vs. safety plans • Explore alternatives to suicide • 3rd person exploration • Separate suicidal feelings from the self (the desire is to eradicate the feelings – not the self) • Neodissociation

50. Remember the targets • Psychache or intense distress • Interpersonal theory: Social disconnection, thwarted belongingness, or perceived burden • Hopelessness for positive change • Arousal or agitation • Desensitization • Problem-solving deficits [mental constriction] • Lethal means