Advancing treatment. Transforming lives. Mindfulness, Acceptance, and Compassion in Service of Suicide Prevention Thomas E. Ellis, PsyD, ABPP The Menninger

Advancing treatment. Transforming lives.

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Advancing treatment. Transforming lives.Advancing treatment. Transforming lives.

Mindfulness, Acceptance, and Compassion in Service of Suicide

Prevention

Thomas E. Ellis, PsyD, ABPPThe Menninger Clinic/Baylor College of Medicine

Houston, Texas

Brazoria County Suicide Prevention SymposiumNovember 6, 2015


Disclosures

• Senior consultant, CAMS-care, LLC


Agenda

• Discuss the emotional impact of suicide risk on patients, providers, and loved ones.

• Describe the psychological process of “reactance,” which sometimes undermines efforts to help.

• Review diagnostic risk factors for suicide and recent developments in understanding and helping suicidal people.

• Outline the place of acceptance in addressing suicide risk.

• Discuss practical implications of these understandings for helpers and loved ones.

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Be careful what you ask for…


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Feelings about Suicide

Suicide is an emotional subject, to patient, provider, and family alike. Some commonly heard comments…

Anxiety/avoidance “Let’s talk about something else.”Hopelessness ”If a person’s really intent on killing

himself, there’s nothing you can to do stop him.”Disdain “It wasn’t serious – just a manipulative

gesture.”Contempt ”If I were him, I’d kill myself, too!” Hostility ”Maybe he’ll get it right the next time.”


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Strong emotions reflexively lead one toward strong responses, such as:

AvoidanceJudgmentEfforts to persuadeDemandsEfforts to controlCoercionInvalidating statements, such as…


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What Does Invalidation Sound Like?Some Examples

• But you have so much to be thankful for!• You know, suicide is a permanent solution to a temporary

problem.• You’re blowing things out of proportion!• Isn’t that against your religion?• But think about what it would do to your family!• If we’re going to work together, you must take suicide off

the table.• Try using some of your skills.• Just try thinking more positively!


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Although well-intentioned, results often are the opposite of what we want.

Common reactions include anger, rigidity, uncooperativeness, greater “resistance”

How are we to make sense of this?

Enter: Reactance


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What is “reactance” and what do butter, bacon, and suicide have in common?


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• Generally speaking, people fiercely defend their freedom and autonomy. This seems to be human nature.

• Psychological reactance is a negative emotional response that occurs when a person feels that someone or something is taking away his or her choices.

• This emotional state often leads to behaviors intended to restore autonomy.

• Examples• Prohibition• Romeo and Juliet• Cigarette smoking• Gun control• Unhealthy behaviors (e.g., Heart Attack Café)

Reactance Theory


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• Reactance can cause one to actually adopt or strengthen an opposing position, and also increases resistance to persuasion.

• Reactance is increased when language is dogmatic or controlling (“must” “can’t” “you’d better or else”).

• During the reactance experience one tends to have angry or hostile feelings, often aimed more at the source of the message than at the message itself.

• Some people are more subject to reactance than others, including those who are highly independent and who struggle with mistrust.

• Defusing reactance is a cornerstone of Motivational Interviewing.• The emphasis of CAMS on collaboration rather than coercion is

intended to create an atmosphere in which the patient can flexibly explore alternatives to suicidal behaviors.

Reactance Theory


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Why Suicide??


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SUICIDE

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To WeaponsHopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

No apparentpsychopathology

Substance Use/Abuse

Psychiatric Illness

Co-morbidity

Suicide: A Multi-factorial Event

Douglas Jacobs, MD


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How is suicide risk affected by psychiatric illness?

No psych dx Unipolar dep Bipolar dis. Schizophrenia Substance dis Any psych dx

Male .72 6.67 7.77 6.55 4.71 4.33

Female .26 3.77 4.78 6.55 3.34 2.10

Percentage of mental health clients dying by suicide, 18-yr follow-up

Nordentoft M, Mortensen PB, Pedersen CB. 2011 Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry, 68,1058-64.


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Psychiatric disorder is not the complete story of suicide. Take depression, for example..

40-50% of people who die by suicide suffer from depression or bipolar disorder

4-7% of people with depression eventually die by suicide

Depression

Suicide

40-50% of people who die by suicide suffer from depression or bipolar disorder


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Trans-diagnostic Contributors to Suicide

• Cognitive rigidity/inflexibility• Problem-solving deficits• Hopelessness• Failed belongingness/burdensomeness• Acquired capability • Dysfunctional attitudes/irrational beliefs • Reasons for living/dying• Self-hatred• Anxiety, insomnia, nightmares• Perfectionism • Rumination• Overgeneral autobiographical memory


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Empirically Supported Interventions for Suicidal Patients

Problem-solving TrainingDialectical Behavior Therapy (DBT)

Rudd and Joiner’s CBTBeck’s Cognitive Therapy for Suicidality

Mentalization-based TherapyCollaborative Assessment and Management

of Suicidality (CAMS)


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Priority focus is to address suicidality and underlying factors.

This involves:• In-depth risk assessment (Suicide Status Form)• Concrete steps to ensure safety in the near-term

(e.g., a written crisis response plan)• Psychotherapeutic intervention to address long-

term vulnerability factors (“drivers”)• All of the above is predicated on the

establishment of an empathic, collaborative therapeutic alliance.

Collaborative Assessment and Management of Suicidality (CAMS)


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??

THERAPIST

PATIENT

CONVENTIONAL MODEL: Suicide as Symptom

DEPRESSIONLACK OF SLEEP

POOR APPETITE

ANHEDONIA ...

? SUICIDALITY ?

Traditional treatment = main focus on the psychiatric disorder (suicidality as symptom). Use of devices such as the no-suicide contract.


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COLLABORATIVELY ASSESSING RISK: Targeting Suicide as the Focus of Treatment

THERAPIST & PATIENT

SUICIDALITY

PAIN STRESS AGITATION

HOPELESSNESS SELF-HATE

REASONS FOR LIVING VS. REASONS FOR DYING

Mood

CAMS Treatment = Intensive intervention that is suicide-specific, emphasizing the development of new means of coping and problem-solving, thereby eliminating the need for suicidal coping.


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• Assessment via Suicide Status Form (collaborative)a. Risk levelb. Identification of “drivers”c. Safety planningd. Problem identificatione. Treatment planning

• Reducing suicidal ideation and behaviora. Problem-solvingb. Development of alternative coping responses

• Psychotherapy to address underlying vulnerabilitiesa. Self-hateb. Relationship issuesc. Etc.

CAMS Key Components

Jobes, D.A. (2006). Assessing and Managing Suicidality. New York: Guilford.


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CAMS Research at The Menninger Clinic


Usual Menninger Care• Medication• Group therapy• Psychosocial groups• Nursing care• Milieu therapy• Family counseling• Vocational counseling• Individual therapy

CAMS Condition

• Medication• Group therapy• Psychosocial groups• Nursing care• Milieu therapy• Family counseling• Vocational counseling• Individual therapy

w/CAMS-M

Treatment Conditions



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Change in depression by treatment group(PHQ-9)

Admission Discharge 5

7

9

11

13

15

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19 18.88

8.83

19.52

13.73CAMS

TAU


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Change in suicidal ideation by treatment group(Beck Scale for Suicidal Ideation)


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5

7

9

11

13

15

13.75

4.82

15.06

9.35 CAMS

TAU


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Change in hopelessness by treatment group (Beck Hopelessness Scale)


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5

7

9

11

13

15

12.62

6.25

15.15

14.42

CAMS

TAU


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Change in suicidal cognitions by treatment group (Suicide Cognitions Scale)


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40

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50

55

60

53.61

33.27

59.98

50.79

CAMS

TAU


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Change in experiential avoidance by treatment (Acceptance & Action Questionnaire)


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28

30

32

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36

38

40

34.79

24.48

36.65

33.77

CAMS

TAU


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Advancing treatment. Transforming lives.Advancing treatment. Transforming lives.

PHQ 9 BSS SCS BHS AAQ0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8 1.67

1.031.18

1.11 1.11.01

0.59 0.58

0.20.33

CAMSTAU

Effect Sizes: TAU vs. CAMS


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For more information about CAMS…

www.cams-care.com

http://www.cams-care.com/


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So, how does all of this relate to acceptance?

Let’s start with a little context…


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The Evolution of “Third-wave” Therapies

1st wave: Behavior therapy (e.g., systematic desensitization)

2nd wave: Cognitive-behavior therapy (cognitive restructuring)

3rd wave: Dialectical Behavior Therapy (DBT), Integrative Couple Therapy (ICT), Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy (MBCT), etc.


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The “Third Wave”The change vs. acceptance issueThings that tend not to change

One’s pastTemperamentLossChronic pain

The paradox of effort to control inner experience

Pink elephantsTip-of-tongue phenomenonSleep

Acceptance as an alternativePanic disorderCouples therapy

AAQ data (experiential avoidance)Menninger Suicide Resilience groupCAMS


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Acceptance

What it is• Acknowledging reality• Meeting a person where

he/she is• Not judging/condemning• A starting point for

change• Leaving doors open

What it is not:• Approval• Agreement• Resignation• Closing doors


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• Attending to the present moment• Awareness of sensations, thoughts, and emotions• Practicing nonjudgmental acceptance (yes, even of

suicidal thoughts)• Distinguishing between inner experience

(thoughts, feelings) and actions• To learn more: Luoma & Villatte (2012). Mindfulness in the

treatment of suicidal individuals. Cognitive and Behavioral Practice, 19(2), 265-276.

Cultivating Acceptance:Mindfulness as Method


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To be in a position to help a suicidal individual, it is important to cultivate understanding of and empathy for the suicidal wish…

How might we cultivate such empathy?

Empathy is helpful as well…


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Who said this?I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I cannot tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me.

-A. Lincoln, 1841


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Recommended Reading

An Unquiet Mind, by Kay JamisonDarkness Visible, by William StyronThe Savage God, by A. AlvarezHoliday of Darkness, by Norman EndlerWaking Up, by Terry WiseStruck by Living, by Julie HershCry of Pain, by Mark Williams


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Cultivating empathy…

Try this thought experiment:

Think of a highly personal fact about yourself, one that you have never disclosed to anyone else.

Now imagine being asked to disclose this to someone whom you have only recently met.

Further imagine that this person is in a position of considerable power and that you are not at all convinced that he/she is on your side.

How would you behave?

What would you most need?


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Aspects of Intervention with Suicidal Patients

Crisis stabilization: Surviving the suicidal episode “Containment”Means restrictionStabilization of mood and sleepSupport

Treatment: Addressing vulnerabilities to suicideHopelessnessCoping deficitsSelf-hatredRelationship issues

The importance of “staying therapeutic”Managing emotionsProviding validating (rather than invalidating) responses


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Validating Responses:Some Examples

• You must be really hurting if suicide has started to come to mind.

• Suicide is a scary topic; OK if we talk about it anyway?• Given all you’re dealing with, no wonder suicidal thoughts

have shown up.• Sounds like it’s hard for you to imagine things ever getting

better.• It’s normal to want relief from suffering. Can we talk about

some ways other than suicide?• I understand it’s hard to “take suicide off the table.” Maybe

we can put some other things “on the table.”


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• Using relationship to keep the conversation going, buying time• Focusing on needs (relief from suffering)• Accepting that you can’t do it all alone• Stance of acceptance

• Acknowledging it’s here (suicide risk)• Acknowledging (and accepting) your own feelings (e.g., “It

scares me to hear this”)• Refraining from “common-sense” advice (e.g., “You must

promise you won’t kill yourself.”)• Refraining from the no-suicide contract

• Noting that thoughts are ok; they don’t have to lead to action• Concerning reactance: So should I say, “Go ahead, kill yourself?” • Um, no.• Mindfulness reminder re: staying in the present (vs. past

(rumination) or future (catastrophizing))• Cultivating empathy and compassion concerning suffering

Employing Acceptance in Helping a Suicidal Person


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Kevin Berthia, eight years later, at the American Foundation for Suicide Prevention’s annual dinner in New York, where he presented Officer Kevin Briggs with an award for public service.


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Thanks!

Tom [email protected]

mailto:[email protected]

Documents

Advancing treatment. Transforming lives. Mindfulness, Acceptance, and Compassion in Service of Suicide Prevention Thomas E. Ellis, PsyD, ABPP The Menninger