Suicide Assessment and Intervention

1. Suicide Assessment and Intervention John Sommers-Flanagan, Ph.D., University of Montana Department of Counselor Education John.sf@mso.umt.edu or johnsommersflanagan.com

2. Preparation • The content of this workshop includes emotionally difficult material (and why I like that) • Take breaks and engage in self-care as needed • INFORMED CONSENT • Are you ready? Seriously.

3. Learning Objectives • Build Your Suicide Knowledge • Bust five BIG suicide myths • Deepen your understanding of the phenomenon of suicide (e.g., eight risk dimensions) • Articulate the pros, cons, and caveats of assessing suicide risk among students and clients • Review the SPRC Suicide Assessment and Management Competencies

4. Learning Objectives II • Practice Suicide Assessment & Intervention Skills • Learn, develop, and practice skills for collecting accurate suicide assessment information • Integrate eight suicide risk dimensions into your suicide assessment and intervention process • Develop and practice skills for (a) asking directly, (b) assessing social connection, (c) assessing hopelessness, (d) dealing with irritability, (e) collaborative safety planning, (f) lethal means restriction, (g) 5 different intervention techniques, and more.

5. Learning Objectives III • Develop Your Self-Awareness and Refine Your Attitude Toward Suicide • Explore your attitudes toward and reactions to suicide and talk about suicide • Imagine how you would face and cope with completed suicides • Track, throughout the workshop, how the process of acquiring suicide knowledge and practicing suicide assessment and intervention skills, affects you psychologically and emotionally.

6. Our Ground Rules Include • Opennessto Learning • Commitmentto being Respectful • Willingness to Participate in Learning Activities • A commitment to SELF-CARE

7. And Remember • This is YOUR workshop • Your input and comments are welcome, not mandatory (I will keep us on track – more or less) • Let’s have as much fun as we can while learning together about a very challenging topic

8. Insights – One Dialectic • There are two basic, albeit contradictory, truths about suicide: (A) Suicide should never be committed* when one is depressed (or disturbed or constricted); and (B) almost every suicide is committed* for reasons that make sense to the person who does it. --E. Shneidman

9. Bust A Big Myth – I • Suicidal thoughts and gestures ARE SIGNS OF DEVIANCE • Nah: 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 • Relax, NORMALIZE, and explore suicide ideation for what it is: an expression of distress

10. *Big Myth – I • Normalize and ask directly – Practice • Turn to your neighbor • “It’s not unusual when . . .” • “to have thoughts of suicide . . .” • “I wonder if that’s true for you?” • Reactions

11. Bust A Big Myth – II • When conducting assessments, we should look for pathology • Not so: That just makes students and clients feel worse about themselves • Your judgments increase the distance between you and your client • Instead: We look for and highlight STRENGTHS [*What helps? Even just . . .*]

12. Bust A Big Myth – III • As professionals, we emphasize risk factor assessment and diagnostic interviewing • Nope . . . IS PATH WARM. . . SAD PERSONS • Suicide is unpredictable (< our preoccupation) • People don’t want to be pigeon-holed or labelled • Instead, we work with students, parents, and clients to address risk and increase protection

13. Case 1 – Kennedy – Opening • Kennedy is a 15-year-old referred by her parents • This is session #1: 1:21 – 5:17 • Watch for: (a) first mention of suicide; (b) first focus; (c) problem-solving; (d) “gun” mention

14. Kennedy – 1 – Discussion • First mention of suicide (*Variations) • First focus (Distress . . . Why? Not P, but D) • What have you tried? (After listening+ . . .) • Gun mention

15. Bust A Big Myth – IV • We are medical authorities who evaluate and [ELIMINATE] suicide ideation • Nyet:Linehan; we collaborate (CAMS) • Suicide contracts are out • Collaborative safety planning is in

16. Bust A Big Myth – V • Suicide is 100% preventable • Negatory: A secret . . . Suicide rates are very stable • Prevention efforts account for very little (if any) variance in overall suicide rates • If you think you’re going to move that needle, you’re delusional. But you might make a HUGE difference to the person you’re sitting with. • 100% prevention messages make people guilty

17. Clinician Knowledge: Myth Busting

18. Awareness • Let’s imagine an unpleasant scenario • Survey Questions (How many of you have . . .?) • Most of us will have contact with individuals who are suicidal . . . at a rate higher than we suspect

19. Awareness – Reflections • Talk with your table about: • What you felt in your body, and where • What thoughts passed through your mind? • What emotions did you experience? • Anything else triggered?

20. Reflections II • Suicide is probably the biggest stressor that clinicians (and humans?) face • Anxiety and irritation [waste of time] • Practice is essential! • But practicing will be triggering • What are your BELIEFS about suicide?

21. Knowledge • Now let’s intellectualize • In 1949, Edwin Shneidman, a suicidology pioneer . . . • Discovered several hundred suicide notes in a coroner’s vault • But did not read them

22. Knowledge II • Consequently, he discovered “Psychache” • “In general, it is probably accurate to say that suicide always involves an individual’s tortured and tunneled logic in a state of inner-felt, intolerable emotion. In addition, this mixture of constricted thinking and unbearable anguish is infused with that individual’s conscious and

23. Knowledge III • unconscious psychodynamics (of hate, dependency, hope, etc.), playing themselves out within a social and cultural context, which itself imposes various degrees of restraint on, or facilitations of, the suicidal act”

24. Knowledge IV • Remember this: “No psychache. No suicide.” Psychache and what contributes to it is the primary focus of treatment. • Now we call it psychological pain or intolerable/ unbearable distress • What makes unbearable distress for one person may not for the next person

25. Knowledge V Base Rates Death by suicide is infrequent: 13.4/100,000 – US [Highest since 1986] or 0.013% . . . Youth under 14 is 0.7/100,000 or 0.007% [Classroom teacher 30 x 30; SC examples: 1000 x 30] The math: 13.4 x 25* = 335 per 100,000 or 0.00335% or 1 of every 298 Americans with MDD All 298 have MDD, which one will die by suicide? The answer: We don’t know.

26. Risk Factors -- Critique • There are NO GOOD RISK FACTORS (Spring) • You can’t accurately predict suicide based on risk factors • Risk factors must be individualized

27. Knowledge VI • Examples 25+ . . . But they can also protect • New SSRI prescription; Previous attempts; Cutting • Illness; Male; Insomnia + hopelessness; Depression with Panic • Remember: No predictors substitute for a good suicide assessment interview with follow up

28. Insights II • At present it is impossible to predict accurately any person's suicide. Sophisticated statistical models. . . and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient [dies by] suicide while nine other equally depressed and equally suicidal patients do not, I answer, "I don't know". – R. Litman

29. Mood scaling – Assessment Kennedy Demo of Mood Scaling with a Suicide Floor [WIDE 2: 1:22 TO 4:56]

30. Kennedy – 1A – Discussion • What did you learn about Kennedy? • I went to problem-solving – why? • PS is BOTH . . . and • Where else could you take the Mood Scaling? • Will do PS on gun later

31. Mood rating Practice • May I ask some questions about your mood? • 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?

32. Mood rating – reflections Be with your supportive table partners 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)? • Normalizing, asking directly, gentle assumption

33. Knowledge VIi: 8 Risk Dimensions • Intolerable or unbearable distress [The core] • Social disconnection [thwarted belonging or perceived burden] • Hopelessness [“nothing helps”] *Role play now* • Arousal or agitation [diminished self-control] • Intent and/or planning [movement toward] • Desensitization [alcohol; drugs; cutting] • Problem-solving deficits [mental constriction] • Lethal means is available [firearms in U.S.]

34. Kennedy – PROBLEM-SOLVING • Problem-solving is both assessment and intervention for the possibility of PS impairment • WIDE 2: 4:56 – 9:55 • What does PS address?

35. Kennedy – ALTERNATIVES TO suicide • Shneidman technique [1:13 – 10:35] • Watch for: • Kennedy’s rankings • My collaboration efforts • How I frame my ideas

36. Case 1c – Kennedy – debrief • Table talk on • Kennedy’s rankings • My collaboriononefrts • Framing my ideas

37. Case 1D – Kennedy – safety Planning • Collaborative safety (crisis) planning • This involves collaborative work on identifying individual warning signs, coping responses, social distractions, support networks, and environmental safety (e.g., firearms) • It can flow from “Mood Scaling” • [1:03 – 9:03]

38. safety Planning • Use the handout to practice collaborative safety planning with your partner • Debrief on thoughts, feelings, impulses, and problems

39. CASE 2 – Jeanne – Passive SI Intervention • Active and Passive SI are not the same and warrant different interventions • One size does not fit all • Show Jeanne Clip [3:00 – 9:52] discuss, then [1:27 – 9:07]

40. Table Talk • Do the existential 6 months to live intervention with each other • Debrief: Thoughts, feelings, impulses, other?

41. Cory – Cultural Specificity • Cory – Opening, cultural content, asking about suicide, PTSD Watch for [1:14 – 9:56] What are Cory’s cultural values? Generally and regarding suicide? How will these influence how to work with him?

42. Cory – Cultural Specificity II • Cory – PTSD • Watch for [0:42 – 4:16]: Discuss: What’s your next move? Suicide dimensions/concerns?

43. Case 2 – Chase – Assessment • Chase is a Gay male with a history of suicidality • This is the beginning of session #1 • Watch for [2:04 – 6:58] then [6:59 – 11:52]: (a) Asking directly; (b) normalizing; and (c) the risk dimensions

44. Chase – Discussion With your table discuss: • How you felt/reacted to John asking directly so early and my use of normalizing • What risk dimensions do you immediately see • Remember, the risk dimensions point to interventions . . . where do Chase’s point?

45. Chase – Interventions and responses • Show Chase Clip [0:09 – 6:05] • Pattern interpretation • How might you use this social network assessment therapeutically? • Practice? *Role play interpersonal*

46. Chase – assessment II • Show Chase Clip [7:43 – 9:51] then [00 – 5:55] then [5:56 – 9:06] • Which risk dimensions am I trying to assess? [which are active?] • Thoughts on “narrative question” and “projective question” and “friend question”

47. In the end: Decision-Making • No predictive formula; collaborate and use practice standards • Consider Distress + Social Factors + Hopelessness + Intent + Problem-Solving + Agitation + Desensitization + Lethal Means • Go with a collaborative safety plan if possible • Contact parents or guardians, restrict lethal means, intervene on the other seven factors listed above and any idiosyncratic factors as well • Always consult • Document everything, but not primarily as self-protection

48. Chase - Closing With your table, reflect on: What are the “risk dimensions” that make me want to hospitalize Chase? I try to reframe “this time” as different? What are your thoughts on the transport decision?

49. Suicide Assessment and Management: Competency Domains • Attitude and Approach (Self-Awareness) • Understanding Suicide (Knowledge) • Collecting Accurate Assessment Information (Skills) • Formulating Risk (Skills and Clinical Judgment)

50. Suicide Assessment and Management: Competency Domains • Developing a Treatment and Services Plan • Managing Care • Understanding the Legal and Regulatory Issues Related to Suicidality