In case you haven’t seen it, I had an op-ed piece on suicide prevention published in the Missoulian yesterday. I think it has pretty good information, but would like feedback if you have some thoughts on the topic.
Have a great rest of the week.
This is how it goes.
You read, gather background information, do research, and carefully write a manuscript. You put in so many hours or days or weeks that you lose track of how much time you’ve put in—which is a good thing. You re-read, edit, get feedback, revise, and do your best to produce an excellent manuscript. You upload it a portal where it magically finds its way to a professional journal editor. Then, because you can only submit a manuscript to one journal at a time, you wait.
A month passes.
You keep waiting.
If you’re lucky, you hear back from the journal editor via email within two months. You click on the email with a mix of anticipation and dread. Then, ta-da, you learn your manuscript was REJECTED.
The editor is polite, but pointedly informs you that this particular journal doesn’t recognize the magnificence of your work. To add insult to injury, your rejection is accompanied by critiques from three different reviewers. These reviewers were apparently named by Dr. Seuss: Reviewer 1, Reviewer 2, and Reviewer 3.
Some rejections are worse than others. Maybe it’s because your hopes were too high; or maybe it’s because the journal’s impact factor rating was so low. Getting rejected when the journal has an impact rating of “0” can bring down your self-esteem to a similar level.
And then there are the reviewers.
It’s important to remember that reviewers are busy, fallible, human, and unpaid volunteers. They’re also purportedly experts, although I’ve had experiences that led me to question their expertise. Many appear to have a proverbial axe to grind. Perhaps because they experienced scathing critiques in their professional childhood, they feel the need to pass on the pain. Sometimes they just seem obtuse. I’ve wondered a time or two if maybe a reviewer forgot to actually read the manuscript before offering an off-point “review.”
If you sense bitterness, it might be because over the past several years I’ve experienced an extra-large load of rejections. When the New England Journal of Medicine (NEJM) rejected my manuscript in less than a week, I was disappointed. But because the NEJM is the most prestigious journal on the planet, I didn’t linger much on the rejection, because rejection was expected. But when a decidedly less-prestigious professional group rejected all my proposals to present at an annual conference, I was deeply hurt, saddened, and angry. Reading the reviewers’ comments didn’t help.
At one point last summer, in a fit of self-pity, I decided to count up my two-year rejection total. I got to 20, had a flash of insight, and stopped. It was like counting cloudy days. My advice: Unless you’re especially serious about depressing yourself, don’t count up your rejections. If you’re into counting, put that energy into counting the sunny days.
One time, back when I was immature and impulsive, I received an insensitive and insulting rejection from a low tier journal. My response: A hasty, nasty, and indignant email lambasting the editor and his single reviewer for their poor decision-making process and outcome. Sending the email was immediately gratifying, but, like many immediately gratifying things, not reflective of good judgment. I never heard back. And now, when I see that editor at conferences, it’s awkward.
More recently, I responded to a rejection from a high-status conference with humility along with a gentle inquiry about re-consideration. Less than 24 hours later they discovered “one more slot” and I was in! It was a paid gig, for an excellent conference, and at a convenient venue. Bingo. Let that be a lesson to me.
Last month I received a different sort of journal rejection. It was an invitation to “Revise and Resubmit.”
Put in romantic terms, revise and resubmit is lukewarm and confusing. The message is, “I kind of like you, and you have potential, but I’m not ready for a commitment.” But if you’ve been casting out and reeling in a raft of rejections, revise and resubmit is a welcome flirtation.
I had submitted a manuscript focusing on suicide risk assessment to a reasonably good journal. It was a good manuscript. In fact, Reviewer 3 recommended publication. But Reviewer 1 spoiled my day by offering 23 substantial and picky suggestions. The editor, who wrote me a long and rather nice email, decided to go with Reviewer 1’s opinion: revise and resubmit.
Given that I’ve been reviewing the suicide risk assessment literature for a couple decades, I assumed I was well-versed in the area. But when I read through Reviewer 1’s suggestions I was surprised, humbled, and eventually pleased. Reviewer 1 had many excellent points.
Looking back and forward, I think this is what I like best about submitting manuscripts to professional journals. Basically, you get a free critique and although some reviewers are duds, others are experts in the field who provide you with a fabulous educational opportunity. There’s always so much more to learn.
The moral of this story and blog post is that the attitude we have toward rejection is far more important than our fragile egos (at least it’s more important than my fragile ego). In response to the revise and resubmit verdict, I’ve graciously accepted the feedback, engaged a co-author to help me, and we have now systematically plowed through the 23 recommendations. The result: Last week we re-submitted a vastly improved manuscript.
Now we wait.
Although I have hope for success, I also realize that Reviewer 1 may have a bit more educational feedback to offer. But this time around, I’m looking forward to it.
I had a nice time today with the Student Health and Student Support staff of Montana State University Billings. Not only were they awesome, they were also awesomely dedicated to suicide prevention on their campus. Given that Spring is coming, that’s an excellent thing.
A link to the powerpoint for today’s talk is below:
This is the second follow up post to the MUS Suicide Summit in Bozeman this past week. It focuses on specific suicide interventions. As I looked through this and the material in the previous post, it reminded me that Dr. Janet P. Wollersheim was a huge influential force in my understanding of suicide assessment. Thanks Dr. Wollersheim!
The following sections consist of basic ideas about suicide intervention options during a suicide crisis. These guidelines are consistent with Shneidman’s (1996) excellent advice for therapists working with suicidal clients: “Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit” (p. 139).
Listening and Being Empathic
The first rule of working therapeutically with suicidal clients is to listen empathically. Your clients may have never openly discussed their suicidal thoughts and feelings with another person. Use basic attending behaviors and listening responses (e.g., paraphrasing and reflection of feeling) to show your empathy for the depth of your clients’ emotional pain is a solid foundation.
Establishing a Therapeutic Relationship
A positive therapy relationship is important to successful suicide assessment and effective treatment. In crisis situations (e.g., suicide telephone hotline) there’s less time for establishing therapeutic relationships and more focus on applying interventions. However, whether you’re working in a crisis or therapy setting, you should still use relationship-building counseling responses as much as possible given the constraints of your setting.
Within the CAMS approach, assessment is used to help therapists understand “the idiosyncratic nature of the client’s suicidality, so that both parties can intimately appreciate the client’s suicidal pain and suffering” (Jobes et al., 2007, p. 287). At some point after you’ve “intimately appreciated” your client’s suicidality, you may then make an empathic statement to facilitate hope:
I hear you saying you’re terribly depressed. Despite those feelings, it’s important for you to know that most people who get depressed get over it and eventually feel better. The fact that we’re meeting today and developing a plan to help you deal with your emotional pain is a big step in the right direction.
Clients who are depressed or emotionally distressed may have difficulty remembering positive events or emotions (Lau et al., 2004). Therefore, although you can help clients focus on positive events and past positive emotional experiences, you also need empathy with the fact that it isn’t easy for most clients who are suicidal to recall anything positive.
Clinician: Can you think of a time when you were feeling better and tell me what was happening then?
Client: (in a barely audible voice) No. I don’t remember feeling better.
Clinician: That’s okay. It’s perfectly natural for people who are feeling depressed to not be able to remember positive times.
Suicidal clients also may have difficulty attending to what you’re saying. It’s important to speak slowly and clearly, occasionally repeating key messages.
Helping clients develop practical plans for coping with and reducing psychological pain is central to suicide intervention. This plan can include relaxation, mindfulness, traditional meditation practices, cognitive restructuring, social outreach, and other strategies that increase self-soothing, decrease social isolation, improve problem-solving, and decrease feelings of being a social burden.
Instead of traditional no-suicide contracts, contemporary approaches emphasize obtaining a commitment to treatment statement from clients (Rudd et al., 2006). These treatment statements or plans go by various names including, “Commitment to Intervention,” “Crisis Response Plan,” “Safety Plan,” and “Safety Planning Intervention” (Jobes et al., 2008; Stanley & Brown, 2012). These statements describe activities that clients will do to address depressive and suicidal symptoms, rather than focusing narrowly on what the client will not do (i.e., commit suicide). These plans also include ways for clients to access emergency support after hours (such as the national suicide prevention lifeline (800) 273-TALK or a similar emergency crisis number.
Stanley and Brown (2005) developed a brief treatment for suicidal clients, called the Safety Planning Intervention (SPI). This intervention was developed from cognitive-therapy principles and can be used in hospital emergency rooms as well as inpatient and outpatient settings (Brown et al., 2005). The SPI includes six treatment components:
1. Recognizing warning signs of an impending suicidal crisis.
2. Employing internal coping strategies.
3. Utilizing social contacts as a means of distraction from suicidal thoughts.
4. Contacting family members or friends who may help to resolve the crisis.
5. Contacting mental health professionals or agencies.
6. Reducing the potential use of lethal means. (Stanley & Brown, 2012, p. 257)
Stanley and Brown (2012) noted that the sixth treatment component, reducing lethal means, isn’t addressed until the other five safety-plan components have been completed. Component six also may require assistance from family members or a friend, depending on the situation. All six of these components should be included in your documentation, including firearms management.
Identifying Alternatives to Suicide
Engaging in a debate about the acceptability of suicide or whether with clients with suicidal impulses “should” attempt suicide can backfire. Sometimes suicidal individuals feel so disempowered that they perceive the possibility of killing themselves as one of their few sources of control. Rather than argue, your focus is on helping clients identify methods for coping with suicidal impulses and find more desirable life alternatives. .
Suicidal clients may be unable to identify options to suicide. As Shneidman (1980) suggested, clients need help to “widen” their view of life’s options.
Shneidman (1980) wrote of a situation in which a pregnant teenager came to see him in suicidal crisis. She had a gun in her purse. He agreed with her that suicide was an option, while pulling out paper and a pen to write down alternatives to suicide. Shneidman generated most of the options (e.g., “You could have the baby and give it up for adoption”), while she systematically rejected them (“I can’t do that”). He wrote them down anyway, noting they were only making a list of options. Eventually, he handed her a list of options and asked her to rank her preferences. To both of their surprise, she indicated death by suicide was her third preferred option. They worked together to implement options one and two. Happily, she never needed to choose option three.
This is a straightforward intervention. You can practice it with your peers and implement it with suicidal clients. There’s always the possibility that clients will decide suicide is their #1 choice (at which point you’ve obtained important assessment information). However, it’s surprising how often suicidal clients, once they’ve had help expanding their mental constriction symptoms, discover more preferable options; options that involve embracing life.
Separating the Psychic Pain From the Self
Rosenberg (1999; 2000) wrote, “The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self” (p. 86). This technique can help suicidal clients because it provides empathy for their pain, while helping them see that their wish is for the pain, rather than the self, to stop existing.
Rosenberg (1999) also recommended helping clients reframe what’s usually meant by the phrase feeling suicidal. She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than as an “actual intent to take action” (p. 86). Again, this approach can decrease clients’ needs to act on suicidal impulses, partly because of the cognitive reframe and partly because of the therapist’s empathic connection.
Becoming Directive and Responsible
Both ethically and legally, when clients are a clear danger to themselves, it’s the therapist’s responsibility to intervene and provide protection. This mandate means taking a directive role. You may have to tell the client what to do, where to go, and whom to call. It also may involve prescriptive therapeutic interventions, such as urging clients to get involved in daily exercise, recreational activities, church activities, or whatever is preventative based on their unique individual needs.
Clients who are acutely suicidal may require hospitalization. Many professionals view hospitalization as less than optimal, but if you have a client with acute suicide ideation, hospitalization may be your best alternative. If so, be positive and direct. Clients may have negative views of life inside a psychiatric hospital. Statements similar to the following can aid in beginning the discussion.
- I wonder how you feel (or what you think) about staying in a hospital until you feel safer and more in control?
- I think being in the hospital may be just the right thing for you. It’s a safe place. You can work on coping skills and on any medication adjustments you may need or want.
Linehan (1993) discussed several directive approaches for reducing suicide behaviors based on dialectical behavior therapy. She advocated:
- Emphatically instructing the client not to commit suicide.
- Repeatedly informing the client that suicide isn’t a good solution and that a better one will be found.
- Giving advice and telling the client what to do when/if he or she is frozen and unable to construct a positive action plan.
These suggestions can give you a sense of how directive you may need to be when working with clients who are suicidal.
This post is part 1 of a follow up to requests I’ve gotten following the MUS Suicide Prevention Summit in Bozeman. A number of people asked: What’s R-I-P-SC-I-P and how do I get more information about it? The answer is that it’s just an acronym to help practitioners recall key areas to cover in a comprehensive suicide assessment interview. But because I made it up in honor of Robert Wubbolding while doing a workshop in Cincinnati (he’s created several acronyms for Choice Theory and Reality Therapy), I’m pretty much the only source.
The following is a pre-published excerpt from the Suicide Assessment chapter in the forthcoming 6th edition of Clinical Interviewing. It includes some general information, a summary of R-I-P-SC-I-P, and some guidance on how to talk with clients about suicide ideation. Much more of this is in the whole chapter, but I can’t post it here.
Suicide Assessment Interviewing
A comprehensive and collaborative suicide assessment interview is the professional gold standard for assessing suicide risk. Suicide assessment scales and instruments can be a valuable supplement—but not a substitute—for suicide assessment interviewing (see Putting It in Practice 10.1).
A comprehensive suicide assessment interview includes the following components:
- Gathering information about suicide risk and protective factors: This should be done in a manner that emphasizes your desire to understand the client and not as a checklist to estimate risk
- Asking directly about possible suicidal thoughts
- Asking directly about possible suicide plans
- Gathering information about client self-control and agitation
- Gathering information about client suicide intent and reasons to live
- Consultation with one or more professionals
- Implementation of one or more suicide interventions, including, at the very least, collaborative work on developing an individualized safety plan
- Detailed documentation of your assessment and decision-making process (Table 10.3 includes an acronym to help you recall the components of a comprehensive suicide assessment interview)
Table 10.3: RIP SCIP – A Suicide Assessment Acronym
R = Risk and Protective Factors
I = Suicide Ideation
P = Suicide Plan
SC = Client Self-Control and Agitation
I = Suicide Intent and Reasons for Living
P = Safety Planning
These assessment domains or dimensions form the acronym R-I-P-SC-I-P (pronounced RIP SKIP).
Exploring Suicide Ideation
Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.
Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can seem rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.
The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.
Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:
- Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
- I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
- I want my clients to share their suicidal thoughts.
- If my clients share their suicidal thoughts and plans, I can handle it!
If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.
Asking Directly about Suicide Ideation
Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.
Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.
A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:
Well, I asked this question since almost all people at one time or another
during their lives have thought about suicide.
There is nothing abnormal about the thought. In fact it is very normal when one
feels so down in the dumps.
The thought itself is not harmful. (Wollersheim, 1974, p. 223)
A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.
Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask: “When was the last time when you had thoughts about suicide?” Gentle assumption can make it easier for clients to disclose suicide ideation.
Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.
1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)
2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)
4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)
5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)
7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)
The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.
Responding to Suicide Ideation
Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?
First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:
Given the stress you’re experiencing, it’s not unusual that you think about suicide sometimes. It sounds like things have been really hard lately.
This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.
As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.
- Frequency: How often do you find yourself thinking about suicide?
- Triggers: What seems to trigger your suicidal thoughts? What gets them started?
- Duration: How long do these thoughts stay with you once they start?
- Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?
As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.
Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.
Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.
On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.
Tomorrow is the first day of the MUS Statewide Summit on Suicide Prevention in Bozeman, Montana. From 2:30-3:45pm I’ll be participating on a panel: “Screening and Intervention Options with the Imminently Suicidal.” During my 10-12 minutes, I’ll be offering my version of what I view as essential strategies and skills for face-to-face suicide assessment interviewing. Below is the handout for the Summit. I think it’s a great thing that we’re meeting in an effort to address this important problem in Montana. Thanks to Lynne Weltzien of UM-Western in Dillon and Mike Frost of UM-Missoula for the invitation. Here’s the handout . . .
Three Strategies for Conducting
State-of-the-Art Suicide Assessment Interviews
John Sommers-Flanagan, Ph.D.
University of Montana
I. To conduct efficient and valid suicide assessment interviews, clinicians need to hold an attitude of acceptance (not judgment) and use several state-of-the-art assessment strategies.
II. If clinicians believe suicide ideation is a sign of psychopathology or deviance, students or clients will sense this and be less open.
III. Asking directly about suicide is essential, but experienced clinicians use more nuanced assessment strategies.
a. Normalizing statements
- I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
- When people are depressed or feeling miserable, it’s not unusual to have thoughts of suicide pass through their mind. Have you had any thoughts of suicide?
b. Gentle assumption (Shea, 2002, 2004, 2015)
- When was the last time you had thoughts about suicide?
c. A solution-focused mood evaluation with a suicide floor
1. “Is it okay if I ask some questions about your mood?” (This is an invitation for collaboration; clients can say “no,” but rarely do.)
2. “Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now?” (Each end of the scale must be anchored for mutual understanding.)
3. “What’s happening now that makes you give your mood that rating?” (This links the mood rating to the external situation.)
4. “What’s the worst or lowest mood rating you’ve ever had?” (This informs the interviewer about the lowest lows.)
5. “What was happening back then to make you feel so down?” (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
6. “For you, what would be a normal mood rating on a normal day?” (Clients define their normal.)
7. “Now tell me, what’s the best mood rating you think you’ve ever had?” (The process ends with a positive mood rating.)
8. “What was happening that helped you have such a high mood rating?” (The positive rating is linked to an external situation.)
This protocol assumes cooperation. More advanced interviewing procedures can be added if clients are resistant. The goal is a deeper understanding of life events linked to negative moods and suicide ideation and a possible direct transition to counseling or safety planning.
IV. When students or clients disclose suicide ideation clinicians should:
a. Stay calm
b. Express empathy
c. Normalize ideation
d. Move to conducting a full suicide assessment interview (i.e., R-I-P-SC-I-P*) or refer the student/client to someone who will do a full assessment along with safety planning
e. Use suicide interventions as appropriate
V. Using Shneidman’s “Alternatives to Suicide” approach is a parsimonious way to simultaneously assess and intervene to reduce danger to self
VI. IMHO: All health and mental health providers should be trained to use these clinical skills and strategies when working with potentially suicidal students/clients.
Adapted from: Clinical Interviewing (6th ed., 2016), Wiley. Feel free to share this handout as long as authorship is included. For more information or to ask about professional workshops for your organization, contact John Sommers-Flanagan: email@example.com or 406-721-6367.