Suicide Assessment, Intervention, and Coping

1. Suicide Assessment, Intervention, and Coping Professional and Community Collaboration for Suicide Prevention John Sommers-Flanagan, Ph.D. Department of Counselor Education University of Montana john.sf@mso.umt.edu See: johnsommersflanagan.com for additional information on suicide assessment and intervention

2. Intro • Let’s Get Some Things Straight • We are all ABNORMAL (How are you?) • Educators and mental health workers are . . . _____________ • If I were running for public office: Econ, Env, Just, etc . . . all run through E & MH • We will cover . . . In 6 hours . . . hahaha • Three days later . . . • But reality is what it is . . .

3. Big Objectives Set and achieve group and personal goals for developing skills for suicide assessment, intervention, and prevention Talk about the idea of working with depressed and/or suicidal clients or students and ideas about prevention

4. Little Objectives Learn a six-part depression-suicide assessment interview protocol Define and understand differential activation theory Learn how to incorporate solution-focused or narrative techniques into traditional suicide assessment Learn three specific individual suicide intervention techniques

5. Little Objectives (cont) Understand the therapeutic relationship principles that support professional-community suicide prevention And do all this (become more knowledgeable and skilled) in the context of a supportive, respectful, and fun learning community

6. What We Need Today • Openness to Learning • Commitment to being Respectful • Willingness to Participate in Learning Activities • Flexibility about new ppt items

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

8. Preparation (Awareness) • The content of this workshop includes emotionally difficult material (and why I like that) • Please take breaks and engage in self-care as needed • Are you ready?

9. Preparation II • Let’s imagine an unpleasant scenario • Survey Questions (How many have) • Most of us will have contact with individuals who are suicidal either professionally or personally . . . And probably at a rate much higher than we suspect

10. Preparation III • 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

11. Preparation IV • And he discovered “Psychache” • Great quotation: • “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

12. Preparation V • 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”

13. Preparation VI (Knowledge) • Why Suicide: Suicide Theories • Shneidman (psychache + mental constriction + perturbation) • Joiner (interpersonal theory—thwarted belongingness and perceived burden) • Inflammation • Altitude and neurotransmitters • Seasonal Affective Disorder

14. Preparation VII • Common Reasons for Suicide • “I knew everyone would be better off if I were dead. It would end my misery and relieve their burden.” [Joiner’s theory adapted from D. Meichenbaum] • “I can’t stand the pain any longer. I’ve tried everything.” [Shneidman] • Others??

15. Coping and Self-Care #1 Using inspiration to cope with emotional challenges MLK Clip While watching this video, write down your three biggest goals for today What are your dreams for yourself and for those with whom you work?

17. Our Job • Develop awareness, knowledge, and skills • And then use these to help preserving the lives of those with whom we work (while recognizing the viability of PAS)

18. Now . . . Let’s. . . BUST the Big Suicide Myth

19. The Big MYTH or Old Narrative • Suicide ideation is a sign of DEVIANCE • This is the old medical model view • Then . . . we, as medical authorities, assess and intervene with suicidal patients [We stop them; we side with life]

20. The Problem of Suicide

21. Why 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

22. The Problem of Suicide Attempts

23. Why Bust the Big Myth II How we think about suicide affects how we treat suicidal people If we THINK it represents DEVIANCE, people with suicidal thoughts will FEEL more isolated If we’re scared of suicidal thoughts, then we transmit that message to our clients

24. Why Bust the Big Myth? III The Constructive Rationale: “Words were originally magic and to this day words have retained much of their ancient magical power. By words one person can make another blissfully happy or drive him [or her] to despair . . . . Words provoke affects and are [a] means of . . . influence. . .”

25. The New Big Narrative • Suicide thoughts and gestures don’t represent deviance • Suicide thoughts and gestures represent DISTRESS • We have empathy WITH clients and their distress, viewing suicide ideation and behavior as a means through which they express their distress or unhappiness

26. Five-Minute Reflection • Questions to discuss with each other • What issues/ideas, etc., activate my depression-suicide buttons? • What are my beliefs and attitudes about suicide (religious or ethics-related ideas)? • How can I embrace the idea that suicidal thoughts are natural and be comfortable with that? • Debrief together

27. Suicide Science (the numbers) • Now we’ll keep intellectualizing and look at the numbers in two ways • Base rates • Risk factors (suicide predictors)

28. The Numbers (U.S. data) • Death by suicide is a low base rate phenomenon among adolescents: • About 10-12 per 100,000 • And among adults • 12.6 per 100K or 0.0126% for 2013

29. Suicide Over Time (U.S.) • 1986: 12.5/100,000 • Then it steadily decreased to: • 2000: 10.4/100,000 • Then it steadily increased to: • 2013: 12.6/100,000 • These are the latest figures available

30. Suicide and Age (2013 data) • Highest: 45-64 years = 19.1/100,000 • Then: 85 and older = 18.6/100,000 • Lowest: Under 14 years = 0.7/100,000 • See: https://www.afsp.org/understanding-suicide/facts-and-figures

31. Suicide by Race/Ethnicity

32. Death by Suicide and Sex • Using the historic binary sex classification, the numbers are: • Males: 20.2 per 100,000 • Females: 5.5 per 100,000 • Here’s something interesting: Boys with a previous attempt are 30 times more likely to die by suicide than boys who haven’t (Girls: 3 Xs more likely)

33. Suicide Methods (U.S.)

34. Suicide by State

35. Vulnerable Groups in MT • Native Americans: 26.2 per 100K • Veterans: 54 per 100K • Veterans under age 25: 166 per 100K (this is where some of our risk factor data becomes very important: 0.166%) • See Karl Rosston’s excellent Montana Strategic Suicide Prevention Plan

36. Suicide Interview Components 1. Suicide risk factors 2. Suicide ideation 3. Suicide plan (SLAP) 4. Self-control 5. Suicide intent 6. Safety planning and other suicide interventions (esp. Protective factors) • S6 or R-I-P-SC-I-P

37. Risk Factor Activity • Go through the risk factor checklist (handout) with a partner (or 2 or 3) • Identify the ones that seem familiar • Notice what seems new • Discuss them with each other

38. Differential Activation • Low mood is associated with biases in memory, negative interpretations, and attitudes, and problem-solving deficits • Return of a low mood reactivates these patterns

39. Differential Activation • If the content of what is reactivated is global, negative, and self-referent (e.g., “I am a failure; worthless and unlovable.”) • Then relapse and recurrence of depression (with SI) is highly likely. (Lau, Segal, & Williams, 2004, p. 422)

40. Gloomy Sunday • https://youtu.be/KUCyjDOlnPU • Billie Holiday – 1941 version • Originally: The Hungarian Suicide Song

41. Gloomy Sunday II • “The influence of music on suicide may be contingent on societal, social, and individual conditions, such as economic recessions, membership in musical subcultures, and psychiatric disturbance” (p. 349) • Stack, Krysinska, and Lester (2007)

42. Coping and Self-Care #2 3-Step Emotional Change Trick • Feel the feeling [Honor it] • Think a new thought or do something different • Spread the good mood • _________________

43. Y-M-C-A • One mood elevator

44. Assignment for Tomorrow • Note cards are here and there • Write notes to me about what you want to learn about grief from a multicultural perspective • Tomorrow afternoon we’ll have a Native American panel to answer your questions

45. Skills! • Now we turn from Awareness and Knowledge to Skills (mostly) • The focus will be on HOW we interview or talk with suicidal individuals

46. Shawn Shea on Gentle Assumptions • https://www.youtube.com/watch?v=MCqlLCR5mEs • 2:21 to 5:51 to 7:15 • Where is Shea on our RIPSCIP protocol?

47. Suicide Interview Components 1. Suicide risk factors 2. Suicide ideation 3. Suicide plan (SLAP) 4. Self-control 5. Suicide intent 6. Safety planning and other suicide interventions (esp. Protective factors) • S6 or R-I-P-SC-I-P

48. Suicide Risk Factors I = Ideation S = Substance Use P = Purposelessness A = Anxiety T = Trapped H = Hopelessness

49. Suicide Risk Factors W = Withdrawal A = Anger R = Recklessness M = Mood Change See: http://johnsommersflanagan.com/2013/07/12/is-path-warm-an-acronymn-to-guide-suicide-risk-assessment/ [Where is depr/loneliness?]

50. Asking About Suicide Ideation Ask directly Use the word “suicide” when describing limits to confidentiality Use the word “suicide” when asking about suicide (not: “harm to self”) Frame the question appropriately Make the supposedly deviant response feel more normal