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 • My favorite topic • Emotionally difficult, but emotionally important • Trigger warning: Rick story + breaks/self-care • INFORMED CONSENT – Are you ready?

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 • Practice suicide assessment skills • Integrate eight suicide risk and strength dimensions into your suicide assessment and intervention process • Develop and practice assessment and intervention skills for (a) asking directly, (b) social connection, (c) hopelessness, (d) dealing with irritability and agitation, (e) safety planning, (f) lethal means restriction, and (g) additional intervention techniques.

5. Learning Objectives III • Develop Self-Awareness and Refine Your Attitude Toward Suicide • Explore your attitudes toward and reactions to suicide • Imagine how you might cope with a completed suicide • 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 • 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 heavy topic

8. Insights • 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 • About 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. 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 acknowledge pain, while looking for and highlighting STRENGTHS

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

12. 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

13. Bust A Big Myth – V • Suicide is 100% preventable • Negatory: A secret . . . Suicide rates are mostly 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 increase guilt [CK]

14. Clinician Knowledge: Myth Busting

15. Practice Activity – 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

16. Practice Activity – 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? • What helps you cope?

17. Reflections II • Suicide includes many emotional triggers. What are yours? • History – yourself or loved ones • Waste of time • Fear of bad outcomes and litigation – JSF story • Practice is essential! • But practicing will be triggering – Practice through it

18. 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

19. 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. . . . this mixture of constricted thinking and unbearable anguish is infused with that individual’s conscious and

20. 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”

21. Knowledge IV • Remember this: “No psychache. No suicide.” Easing psychache is a 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

22. 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% The math: 13.4 x 25* = 335 per 100,000 or 0.335% or 1 of every 298 Americans with MDD All 298 have MDD, which one will die by suicide? The answer: We don’t know.

23. 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

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

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

26. Shawn Shea on Risk and Protective factors • https://www.youtube.com/watch?v=MCqlLCR5mEs • 9:56-10:50 • Conclusion: You can’t predict, but denial + high risk factors and you should contact a third party

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

28. PLUSH AID: 8 Risk Dimensions • Problem-solving deficits [mental constriction] • Lethal means available [firearms in U.S.] • Unbearable or intolerable or distress [The core: Psychache] • Social disconnection [thwarted belonging or perceived burden] • Hopelessness [“nothing helps”] • Arousal or agitation [diminished self-control] • Intent and/or planning [movement toward] • Desensitization [alcohol; drugs; cutting]

29. Case – Kennedy 1 – Opening • Kennedy is a 15-year-old referred by her parents • 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 risk dimensions

30. Kennedy – 1 – Discussion • First mention of suicide • First focus (Distress . . . Why?) • Problem-solving • Gun mention • The risk dimensions **More K** 5:53 – 12:33

31. Case – Kennedy 2 – Mood scaling Demo of Mood Scaling with a Suicide Floor 13:37 – 17:07

32. Kennedy – 2 – Discussion • What did you learn about Kennedy? • I went to problem-solving – why? • P-S is BOTH . . . and • Where else could you take the Mood Scaling? • Will do P-S on gun later

33. 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?

34. 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)?

35. 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)

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

37. Role Play Practice Scenarios • Dealing with irritability • Staying balanced • Dealing with hopelessness • Projective and meta-questions • The social universe assessment

38. Irritability Role Play + Discussion • What you saw • What you felt • What you’ve experienced • Solutions: Staying centered – Taking nothing personally, but being authentic

39. Irritability Strategy • Reflection: “I hear annoyance in your voice” • Light Interpretation: “It seems like that’s partly about how tired you are of feeling bad. Irritability is part of being depressed” • Commitment Statement: “My plan is to keep on working with you and to try not to let any of the annoyance or irritability get in the way of us working together” • Stay Centered: Take nothing personally, but be authentic • Repair: Apologize if you said something offensive

40. Staying Balanced RP + Discussion • What you saw • What you felt • What you’ve experienced • Solutions – How can you stay balanced?

41. Balance Strategy • 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 a little light into the darkness?

42. Hopelessness RP + Discussion • What you saw • What you felt • What you’ve experienced • Solutions – Working from the bottom up

43. Hopelessness Strategy • 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. Projective and Meta-Q Discussion • What you saw • What you felt • What you’ve experienced • Solutions – Just a different lens

45. Projective and Meta-questions • Is it black or blue? • What if your best friend was . . . ? • What does it mean when you feel suicidal? • What if the pain went away, then what? • What if you had six months to live?

46. The Social Universe Assessment • What you saw • What you felt • What you’ve experienced • Solutions – The beginnings of a social intervention

47. The Social Universe Intervention • Who to contact? • How to approach? • Role play process • Role play less-than-optimal outcomes • Re-set goals to what’s controllable

48. Case – Kennedy 3 – safety Planning • Collaborative safety (crisis) planning: • 34:32 – 39:03/39:59 – 43:27 • 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 the “Mood Scaling” assessment technique

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

50. Interventions Alternatives to Suicide • Shneidman Story • Practice and Discussion: • Kennedy 18:00 – 23:46 / 24:15 – 24:49