Suicide Assessment, Intervention, and Coping

Professional and Community Collaboration for Suicide Prevention

John Sommers-Flanagan, Ph.D.John Sommers-Flanagan, Ph.D.Department of Counselor EducationDepartment of Counselor EducationUniversity of MontanaUniversity of Montanajohn.sf@mso.umt.edu john.sf@mso.umt.edu

See: johnsommersflanagan.com for additional See: johnsommersflanagan.com for additional information on suicide assessment and interventioninformation on suicide assessment and intervention

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 . . .

Big Objectives

Set and achieve group and personal Set and achieve group and personal goals for developing skills for suicide goals for developing skills for suicide assessment, intervention, and assessment, intervention, and preventionprevention

Talk about Talk about the idea of working the idea of working with depressed and/or suicidal clients with depressed and/or suicidal clients or students and or students and ideas about ideas about preventionprevention

Little Objectives Learn a six-part depression-suicide Learn a six-part depression-suicide

assessment interview protocolassessment interview protocol

Define and understand differential Define and understand differential activation theoryactivation theory

Learn how to incorporate solution-Learn how to incorporate solution-focused or narrative techniques into focused or narrative techniques into traditional suicide assessmenttraditional suicide assessment

Learn three specific individual suicide Learn three specific individual suicide intervention techniquesintervention techniques

Little Objectives (cont)

Understand the therapeutic relationship Understand the therapeutic relationship principles that support professional-principles that support professional-community suicide preventioncommunity suicide prevention

And do all this (become more And do all this (become more knowledgeable and skilled) in the knowledgeable and skilled) in the context of a supportive, respectful, and context of a supportive, respectful, and fun learning communityfun learning community

What We Need Today Openness to Learning

Commitment to being Respectful

Willingness to Participate in Learning Activities

Flexibility about new ppt items

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

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?

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

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

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

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”

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

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??

Coping and Self-Care #1 Using inspiration to cope with emotional Using inspiration to cope with emotional

challengeschallenges

MLK ClipMLK Clip

While watching this video, write down While watching this video, write down your three biggest goals for todayyour three biggest goals for today

What are your dreams for yourself and What are your dreams for yourself and for those with whom you work?for those with whom you work?

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)

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

The Big MYTH or Old Narrative

Suicide ideation is a sign of DEVIANCESuicide ideation is a sign of DEVIANCE

This is the old medical model viewThis is the old medical model view

Then . . . we, as medical authorities, Then . . . we, as medical authorities, assess and intervene with suicidal assess and intervene with suicidal patients [We stop them; we side with patients [We stop them; we side with life]life]

The Problem of Suicide

Why Bust the Big Myth

Suicidal thoughts and gestures ARE Suicidal thoughts and gestures ARE NOT SIGNS OF DEVIANCENOT SIGNS OF DEVIANCE

About 10% of human population will About 10% of human population will attempt suicideattempt suicide

And 20% will struggle with SI + SPAnd 20% will struggle with SI + SP

Up to 50% of teens are bothered by Up to 50% of teens are bothered by suicidal thoughtssuicidal thoughts

The Problem of Suicide Attempts

Why Bust the Big Myth II

How we think about suicide affects How we think about suicide affects how we treat suicidal peoplehow we treat suicidal people

If we THINK it represents DEVIANCE, If we THINK it represents DEVIANCE, people with suicidal thoughts will FEEL people with suicidal thoughts will FEEL more isolatedmore isolated

If we’re scared of suicidal thoughts, If we’re scared of suicidal thoughts, then we transmit that message to our then we transmit that message to our clientsclients

Why Bust the Big Myth? III

The Constructive Rationale: The Constructive Rationale: ““Words were originally magic and to Words were originally magic and to

this day words have retained much of this day words have retained much of their ancient magical power. By words their ancient magical power. By words one person can make another one person can make another blissfully happy or drive him [or her] blissfully happy or drive him [or her] to despair . . . . Words provoke affects to despair . . . . Words provoke affects and are [a] means of . . . and are [a] means of . . . influence. . .” influence. . .”

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

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

Suicide Science (the numbers)

Now we’ll keep intellectualizing and look at the numbers in two ways

1. Base rates

2. Risk factors (suicide predictors)

The Numbers (U.S. data)

Death by suicide is a low base rate Death by suicide is a low base rate phenomenon among adolescents:phenomenon among adolescents: About 10-12 per 100,000 About 10-12 per 100,000

And among adults And among adults 12.6 per 100K or 0.0126% for 201312.6 per 100K or 0.0126% for 2013

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

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

Suicide by Race/Ethnicity

Race/Ethnicity Rate per 100,000

White 14.2

American Indian 11.7

Asian/Pacific Islander 5.8

Hispanic/Latino 5.7

Black 5.4

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)

Suicide Methods (U.S.)Method Males Females

Firearms 56.4% 31.2%

Suffocation or Hanging

25.2% 23.5%

Pills (81%) and Inhalants (15%)[Poisoning]

11.1% 36.2%

Suicide by State

State Rate per 100,000

Montana 23.7

Alaska 23.1

Utah 21.4

Physicians (U.S.) 20.0

New York 8.1

New Jersey 8.0

District of Columbia 5.8

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

Suicide Interview Components

1. Suicide risk factors 2. Suicide ideation3. Suicide plan (SLAP)4. Self-control5. Suicide intent6. Safety planning and other suicide interventions (esp. Protective factors)

S6 or R-I-P-SC-I-P

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

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

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)

Gloomy Sunday

https://youtu.be/KUCyjDOlnPU

Billie Holiday – 1941 version

Originally: The Hungarian Suicide Song

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)

Coping and Self-Care #2

3-Step Emotional Change Trick

1.Feel the feeling [Honor it]2.Think a new thought or do something different3.Spread the good mood4._________________

Y-M-C-A

One mood elevator

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

Skills!

Now we turn from Awareness and Knowledge to Skills (mostly)

The focus will be on HOW we interview or talk with suicidal individuals

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?

Suicide Interview Components

1. Suicide risk factors 2. Suicide ideation3. Suicide plan (SLAP)4. Self-control5. Suicide intent6. Safety planning and other suicide interventions (esp. Protective factors)

S6 or R-I-P-SC-I-P

Suicide Risk Factors

I = IdeationS = Substance UseP = PurposelessnessA = AnxietyT = TrappedH = Hopelessness

Suicide Risk Factors

W = WithdrawalA = AngerR = RecklessnessM = Mood Change

See: http://johnsommersflanagan.com/2013/07/12/is-path-warm-an-acronymn-to-guide-suicide-risk-assessment/ [Where is depr/loneliness?]

Asking About Suicide Ideation

Ask directlyAsk directly Use the word “suicide” when Use the word “suicide” when

describing limits to confidentiality describing limits to confidentiality Use the word “suicide” when asking Use the word “suicide” when asking

about suicide (not: “harm to self”)about suicide (not: “harm to self”)

Frame the question appropriatelyFrame the question appropriately

Make the supposedly deviant Make the supposedly deviant response feel more normalresponse feel more normal

Asking Directly: Sample Wording

“I ask everyone I meet with about suicide and so I’m going to ask you: Have you had any thoughts about death or about suicide?”

“I’ve read that between 10-50% of teenagers have thought about suicide . . . is that true for you?”

Asking Directly

“Sometimes when people are down or depressed or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?”

Mood rating as a foundation

Suicide Ideation

Frequency

Duration

Intensity

Quality – Listen for active vs. passive suicidal thoughts [Blue vs. Black]

Assessing Suicide Plans

Note: This may flow from risk-factor assessment (previous attempt)

SLAP the PLAN

S – Specificity of the planL – Lethality of the planA – Availability of the meansP – Proximity of social support

Suicide intent

Reasons for living

Severity of previous attempts

Case Example

Tommie video clip 1 – 3:23 on Watch for:

Asking the question directly An effort, albeit inadequate, to check for

exceptions Reflection on the meaning of the “plan”

Practice Time

Volunteer?

Groups of Three Client, Counselor, Observer Brief intro Frame and ask about suicidality Try to get to frequency, duration,

and intensity Switch roles as time permits

Case Example

Tommie video clip 2

Historical Myths about Depression Children can’t get depressed: But they do Depression is mostly biogenetic: But it’s

not Depression is caused by a chemical

imbalance: No one paying attention believes that anymore

Antidepressants are first-line treatment for depression: Only on NPR

And Myths about Suicide

Talking about it is for attention The weather Asking about it might increase the

likelihood Medications are needed Hospitalization is necessary No-suicide contracts are essential

Self control

History of loss of control?

Overcontrol

Self-reported sense of control

What Are We Missing?

Balance

Collaboration

New Big Narrative II The old narrative emphasized diagnostic

interviewing and no-suicide contracts The new narrative implies:

Using strength-based paraphrases Carl Rogers with a twist (O’Hanlon) Exception and externalizing questions Resource questions No assumption of “mental illness” Safety planning

Marsha Linehan and DBT

We balance change and acceptance language

https://www.youtube.com/watch?v=BN_2rP5ldoQ

35:45 – 39:44

Some Linehan Insights

In BPD clients, SI decreases distress

In BPD clients, controlling clients by focusing too much on change increases SI

We don’t know how to decrease suicide risk and the belief that we know what we’re doing has inhibited progress

Protective Factors Good coping strategies Seeking help Positive alliance with health providers Strong faith/religious connection Good social support network Identifies “reasons for living” Safe/supportive school/community Restrictions on lethal suicide means Sobriety

A More Balanced ApproachA More Balanced Approach

Alternatives:Alternatives: What’s happening when you feel What’s happening when you feel

happy or joyful?happy or joyful? What helps you concentrate?What helps you concentrate? When do you feel good?When do you feel good? When do you feel calm and peaceful?When do you feel calm and peaceful? What recreational activities do you What recreational activities do you

enjoy? Or What distracts you from enjoy? Or What distracts you from negative thoughts?negative thoughts?

When do you sleep well?When do you sleep well?

Role Play Demo

Volunteer

Play a role of a suicidal person

John tries to demo

Everyone laughs and critiques

We debrief

Brief Suicide Interventions

No suicide contracts vs. safety plans

Explore alternatives to suicide

3rd person exploration

Separate suicidal feelings from the self (the desire is to eradicate the feelings – not the self)

Neodissociation

Developing a Safety Plan

Tommie clip 3?

Practice protocol

Decision-Making Frequency and intensity and power of

SI (e.g., active vs. passive)

Specificity and lethality of plan

Other risk factors and protective factors (RFL)

Self-control and intent

Decision-Making II

Responsiveness to interventions

Develop safety plan and/or hospitalize

Consultation and documentation

Reach Out and Touch Someone

Community collaboration Linehan (2007) In the absence of high quality

research, we can look at: Clinical wisdom and empirical data on

therapeutic relationships What we have for the current evidence-

base

Evidence-Based Relationships* Genuineness Unconditional Positive Regard Empathic Understanding Therapeutic Alliance

Emotional bond Mutual goals Collaborative techniques/activities

Countertransference Management Client Feedback: Outcome Monitoring *This is our foundation*

Depression/MH Screenings

Schools Community-based (Public health) Medical-based (zero suicide)

If we screen – we must have resources available for treatment and/or referral [Volunteer] Many youth are more comfortable with e-

screening and questionnaires

Using the CSSRS

Columbia Suicide Severity Rating Scale

http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/cssrs_web/course.htm

The emphasis not only on “information”

Targeting Depression

A pill is not a skill (but can help some) Clients often want treatments that

focus on social-emotional-cognitive-behavioral dimensions of life . . .

That have no side effects There’s no stronger medicine than

healthy relationships

Evidence-Based Programs

These are listed on various websites:

http://www.sprc.org/bpr/section-i-evidence-based-programs

Require specific training to implement

The supporting data are mostly meager – View CAST (Coping and Support Training) as an example

The New MantraNormalize

Collaborate

Keep Talking

Focus on Strengths

Consult and Document

Check u

p a

nd

Ch

eck -in

Closing Comments Suicide story

Thanks for listening and participating

For detailed information on suicide assessment interviewing, see: Sommers-Flanagan & Sommers-Flanagan (2014). Clinical Interviewing (5th ed.). Chapter 9; Hoboken, NJ: Wiley

Resources I

Montana Suicide Prevention Resource Center

http://www.sprc.org/states/montana My materials and info is at

johnsommersflanagan.com

Resources II

These are all Google-able National Suicide Prevention Lifeline

(Crisis Hotline) 1-800-273-TALK (8255) 1-800-799-4TTY (4889) TTY

American Foundation for Suicide Prevention (AFSP)

National Institute for Mental Health Suicide Prevention

Resources III

VA Suicide Prevention Department of Defense Suicide

Prevention American Association of Suicidology International Association for Suicide

Prevention (IASP) C-SSRS Website Suicide Prevention Resource Center