Addressing Suicide in Your Practice

1. Addressing Suicide in Your Practice Gary McConahay PhD ColumbiaCare Services, Inc. gmcconahay@columbiacare.org

2. Expanding opportunities for doing therapy with people with suicide thoughts -National Strategy for SP -Affordable Care Act -OHP Expansion -Screening for Depression in Primary Care -Follow up after psychiatric hospitalization

3. What is your experience?

4. What are your worst fears?

5. Stone…1971 • Many therapists unwittingly contribute to the probability of Suicide attempts in ‘suicide-prone’ patients by: • “Externalizing the superego” by mirroring the patient’s self-revilings • “Interrupting autistic defenses” by removing wish-fulfilling fantasies leading to confrontation of unbearable reality • Developing a “symbiotic transference”of an extremely primitive nature that is then broken off

6. Chemtob et al…1989 • Survey says that 22% of psychologists and 51% of psychiatrists had experienced a patient suicide. • “Both groups reported significant disruptions in their personal and professional lives after the patient’s suicide”. • “We argue that patient suicide is an occupational hazard for psychologists and psychiatrists”

7. Hendin et al…2000 • In depth testing and interview with 26 therapists who had lost a patient to suicide • Shock, grief, guilt, fear of blame, self-doubt, shame, anger, and betrayal were major reactions • 21 out of 26 said they would change tx decision: change medication, hospitalize, consult with previous therapist • 19 said they met with family afterwards: almost all were not critical of the therapist

8. Hendin et al…2004 • Questioned 34 therapists whose patients died by suicide • 13 of 34 “severely distressed” by the suicide • Sources of distress: • Failure to hospitalize • Tx decision therapist felt contributed to the suicide • Negative reactions from the therapist’s institution • Fear of a lawsuit by patient’s family

9. Yaseen et al…2013 • Compared 82 therapists who had a patient die by suicide, had a high or low lethality attempt, or die by natural causes regarding how they felt about the patient last visit before they did their act. • Therapists treating imminently suicidal patients had less positive feelings toward their patient but more hopeful for treatment than those treating non-suicidal patients • Felt more overwhelmed, distressed by, and avoidant of suicidal patients

10. Outpatient standards of careBongar 1992 • Maintain appropriate clinician-patient relationships • Evaluate risk: intake and ongoing (e.g. management transitions) • Take adequate history, including records of past treatment • Examine mental status • Diagnose • Plan Treatment

11. Outpatient standards of care (cont) • Specify hospitalization criteria • Obtain consultation & supervision • Properly evaluate need for pharmacological intervention • Properly evaluate suitability of pharmacotherapy provided • Safeguard the environment • Document, Document, Document

12. How close to suicide is my patient? *Get some perspective; not all suicide thoughts mean the same thing *Makes a difference in approach

13. Let’s break it down… • Prevent Death • Address External Factors that contribute to suicide thoughts • Change Internal Factors that foster suicide thoughts • Change Internal Dynamics that predispose the person to suicide thoughts

14. Let’s break it down… • INTERVENTION: Prevent Death • MANAGEMENT: • Address External Factors that contribute to suicide thoughts • Change Internal Factors that foster suicide thoughts • TREATMENT: Change Internal Dynamics that predispose the person to suicide thoughts

15. Intervention • Unless the person has a suicide in progress you have time to talk • As long as the person is talking to you they are safe • Ask directly about suicide • As the conversation progresses, the person feels relieved • As the person feels relieved of pain and they feel hope • When the person feels hope they are less likely to suicide • Ambivalence

16. Intervention 2 • Develop a plan to keep the person safe • That may involve you and it will likely involve others…working together • Go for plans that last hours or days, not weeks

17. Risks and Benefits of Hospitalization +May keep person safe for now +Relieves the therapist’s feeling of responsibility -Stigma, Cost -Hospital stay itself usually changes nothing -Post-hospital discharge period very vulnerable time -May damage therapeutic relationship -Where does the person go for help afterwards?

18. Intervention 3 • Take: Applied Suicide Intervention Skills Training (ASIST) www.columbiacare.org/ASIST

19. Management • Reasons for dying

20. Management • Reasons for Dying can be external or internal • Every reason for dying has embedded within it a reason for living • It is not the event itself but the meaning behind the event • The key meaning is LOSS

21. Management When a person is talking about their reasons for dying they are talking their losses. When a person is talking about their losses, they are talking about what they care about (if they did not care about it, it would not be a loss). When a person is talking to us about what they care about, they are telling us their reasons for living. Therefore, the more reasons for dying we can identify within a person at risk of suicide the more we learn about their reasons for living.

22. ManagementBryan Tanney MD, SuicideCare, 2012

23. Treatment Assumption: Structural and developmental deficits may underlie the suicidal condition.

24. Meanings of suicidal actsBryan Tanney MD, SuicideCare, 2012

25. Treatment Strategies • Repair or support a deficit state, whether structural or developmental • Resolve a focal conflict through enhanced insight • Integrate unhealthy attachment patterns by attending to the treatment relationship • Develop skills to support deficit states and overcome maladaptive coping styles

26. Additional resources Oregon Youth Suicide Prevention listservyspnetwork-bounces@listsmart.osl.state.or.us Oregon Suicide Prevention Coordinator-Donna Noonan Donna.noonan@state.or.us Clinician Survivor’s listserv aascliniciansurvivortaskforce@googlegroups.com

27. Additional Training • ASIST (for intervention) • Suicide to Hope (management and treatment) Gary McConahay PhD gmcconahay@columbiacare.org