Webinar Reflections and a Suicide Myth Quiz

Last week I had the privilege of doing a Wiley Faculty Network Webinar on Teaching Suicide Assessment to graduate students in counseling and psychology. It was a first webinar experience for me and I have a few reflections and a suicide myth quiz from the webinar.

Observation #1: When doing Webinars, keep your eyes on your content (and not the “news feed” with names of friends and colleagues making interesting comments). If you watch the comments you will sound dull and slow – sort of like people sound when they’re talking to you on the phone while watching an engaging television show or surfing the internet.

Observation #2: There are lots of faculty and graduate students out there who want to do their best to help others through suicidal crises. This is very cool. I am always a little verklempt (sp) about how many kind and helpful people there are out there in the world.

Now . . . here’s the suicide quiz. Let’s see how you do. Answer the following True or False. The answers are at the bottom.

  1. Suicide rates are typically highest in rainy and cloudy climates, like Seattle, the Northeast, and the United Kingdom.
  2. Suicide rates are typically highest in the Winter months, especially around the holidays. 
  3. Antidepressant medications (i.e., SSRIs like prozac and celexa) can REDUCE a client’s suicidal impulses.
  4. Antidepressant medications (i.e., SSRIs like prozac and celexa) can INCREASE a client’s suicidal impulses.
  5. Suicide rates in the U.S. are usually higher than homicide rates.
  6. The most common means of suicide among females is firearms.

 

 

 

 

 

 

Answers

 

  1. False.  In the U.S., every year the highest rates are nearly always in Montana, Alaska, Wyoming, and Nevada – and the lowest rates are in the cloudy Northeast
  2. False:  U.S. Suicide rates are nearly always highest in the Spring (April and May, in particular; Mondays have highest rates and Saturdays lowest and, surprisingly, December has the lowest rates).
  3. True:  Yes, there is evidence that antidepressant medications can REDUCE a client’s suicidal impulses.
  4. True:  Yes, there is evidence that antidepressant medications can INCREASE and even CREATE suicidal impulses. [Increased akathisia and violent thoughts]
  5. True:  U.S. Suicide rates (about 30K per year) are typically higher than U.S. homicide rates (about 20K per year).
  6. True:  Firearms constitute the most common method for completed suicides for both females and males.

 

 

 

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March Madness Invitation

Hey. It’s trash talking time. You can join my ESPN based free bracket competition by going to http://espn.go.com/, clicking on The Tournament Challenge and then Join Groups and then finding our group: Montana Trash Talkers. The password is Montana. I plan to win again this year and have forgotten that I didn’t win last year. You’re all toast . . . one and done . . . your performance already sickens me:)

If you’ve received this email feel free to join in or ignore me.

This game is free. If you are the winner of this group, I will send a $50 donation to the charity of your choice. I will also be donating $10 for each of my incorrect selections (from one bracket) to the Missoula Food Bank.

Have an excellent day! I look forward to your participation and trash talking.

John SF

Differential Activation Theory and Suicide Assessment

In anticipation of my upcoming suicide assessment interviewing webinar, I’m posting this and other suicide assessment interviewing material.

Differential Activation Theory

Differential activation theory suggests that when previously depressed and suicidal individuals experience a negative mood, they are likely to have their negative information processing biases reactivated. The original theory:

. . . stated that during a person’s learning history—and particularly during episodes of depression—low mood becomes associated with patterns of negative information processing (biases in memory, interpretations, and attitudes). Any return of the mood reactivates the pattern, and 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 is highly likely. (Lau, Segal, & Williams, 2004, p. 422)

This theory and supporting empirical research indicates that during the course of a clinical interview, certain questioning procedures may move a previously depressed client toward a more negative mood state with an accompanying increase in negative information processing and suicide ideation. In fact, there are many studies indicating that both depressed and non-depressed clients and non-clients can be quickly and powerfully affected by mood inductions (Lau et al., 2004; Mosak, 2000; Teasdale & Dent, 1987).

For example, in a recent study, participants were divided into three groups: (a) those previously depressed with suicide ideation; (b) those previously depressed without suicide ideation; and (c) those with no history of previous depression (Lau et al., 2004). Following a mood challenge in which participants spent eight minutes listening to a depressive Russian opera at ½ speed while reading 40 negative statements such as, “There are things about me that I do not like,” participants generally experienced a worsening of mood and performed more poorly on a cognitive problem-solving test than prior to the mood challenge. Additionally, the participant group with a history of depression and suicide ideation exhibited significantly greater impairment in problem solving than the comparison groups. The authors concluded: “. . . when mood has returned to normal, cognitive variables may return to normal, but those who have been depressed and suicidal in the past are vulnerable to react differentially to changes in mood—with greater deterioration in problem-solving ability” (p. 428). This deterioration in problem solving is consistent with Edwin Shneidman’s concept of mental constriction, which we address later in this chapter.

Overall, the research clearly indicates that all individuals, depressed or not and suicidal or not, can have their mood quickly and adversely affected through rather simple experimental means. Additionally, it appears that previously depressed individuals may experience differential activation and therefore also have increases in negative cognitive biases about the self, others, and the future. Further, it appears that previously suicidal individuals may be particularly vulnerable to having their problem-solving abilities adversely affected when they experience a negative mood state.

Depressogenic Social, Cultural, and Interview Factors

In addition to the preceding research findings, there are a number of contemporary social and cultural factors that may predispose or orient individuals toward depressive and suicidal states. More than ever the United States media is involved in defining depressive states and promoting medical explanations for depression and suicidality. There are many books, magazine articles, and Internet sites encouraging individuals to examine themselves to determine if they might be suffering from depression, bipolar disorder, an anxiety disorder, AD/HD or other mental disorders. In particular, pharmaceutical advertisings encourage individuals to consult with their doctor to determine whether they might benefit from a medication designed to treat their emotional and behavioral symptoms. Unfortunately, as most of us know from personal experience and common sense, it is very easy to move into a negative mood in response to suggestions of personal defectiveness (which, over time, certainly may be as potent as eight minutes of a slow Russian opera). Consequently, it would not be surprising to find that continually rising depression rates and accompanying pharmaceutical treatments are, in part, related to increased awareness of depressive conditions.

Even more relevant to the suicide assessment interviewing process, it may be that interviewers who focus predominantly or exclusively on the presence or absence of negative mood states inadvertently increase such states. This possibility is consistent with constructive theory in that whatever we consciously focus on, be it relaxation or anxiety or depression or happiness, tends to grow. It is also consistent with anecdotal data from our students who report feeling surprisingly down and depressed after conducting and role-playing suicide assessment interviews.

Our concern is that traditional medically oriented depression and suicide assessment interviewing may sometimes inadvertently contribute to, rather than alleviate, underlying depressive cognitive and emotional processes. Consequently, in the following sections on suicide assessment interviewing, we guide you toward balancing negatively oriented depression and suicidality questions with an equal or greater number of questions and prompts designed to increase the focus on more positive client experiences and emotional states. This serves two functions. First, including positive questions and prompts may help clients focus on positive experiences and therefore improve their current mood state and problem-solving skills. Second, if clients are unable to focus on positive personal experiences or display positive affect, it may indicate a more chronic or severe depressive and suicidal condition. Overall, our primary message is that we should always pay close attention to the manner in which we use words, questions, and language when conducting depression and suicide assessment interviews.

Adopting a New Client and Suicide-Friendly Interviewer Attitude

Consistent with the CAMS approach as well as other more recent treatment perspectives (Action and Commitment Therapy (ACT); and Dialectal Behavior Therapy (DBT); we want to encourage you to adopt a fresh new attitude toward clients who may present with depressive and suicidal symptoms. Specifically, consider these attitudinal statements:

Depression and suicidality are natural conditions that arise, in part, from normal human suffering. Consequently, just because a client arrives in your office with depressive symptoms and suicidal features, this does not necessarily indicate deviance—or even a mental disorder.

Given that depressive and suicidal symptoms are natural and normal, it is acceptable for you, as an interviewer, to validate and normalize these feelings if they arise. This is especially important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they are a burden to others (Joiner, 2005). There is no danger in accepting and validating client emotions—even self-destructive emotions.

In the spirit of the CAMS approach, we encourage you to listen to your clients’ suicidal thoughts and impulses nonjudgmentally; these thoughts and impulses represent your clients’ unique efforts to cope with their interpersonal and life problems.

Rather than continually drilling down into your clients’ depressive and suicidal symptoms, be sure to balance your clinical interview with questions that focus on the positive and your clients’ unique reasons for living. Forgetting to ask your client about positive experiences is like forgetting to go outside and breathe fresh air.

Fortunately, most people who experience depression recover, with or without treatment. Additionally, most people at least briefly consider suicide as an alternative to life, and of those who seriously contemplate—or even attempt—suicide, most end up choosing life instead of suicide.

A note of caution is in order. People often hesitate to ask directly about suicidal ideation out of a fear that they will somehow cause a sad person to suddenly think of suicide as an option. Asking about suicidal thoughts or impulses is not the same as dwelling on negative and depressing thoughts and feelings. Balancing the focus between negative and more positive, solution-focused material can be both wise and helpful. Failing to ask about suicide is neither.

Flaws in the Satanic Golden Rule

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Nearly always I learn tons of good stuff from my adolescent clients. A few years ago I learned what “Macking” meant. When I asked my 16-year-old Latino client if it meant having sex (I gently employed a slang word while posing my question), his head shot up and he made eye contact with me for the first time ever and quickly corrected me with a look of shock and disgust. “Macking means . . . like flirting,” he said. And as he continued shaking his head, he said, “Geeze. You’re crazy man.”

The next half hour of counseling was our best half hour ever.

I’m not advocating using the F-word or being an obtuse adult . . . just pointing out how much there is to learn from teenagers.

More recently I learned about the Satanic Golden Rule. A 17-year-old girl told me that it goes like this: “Do unto others as they did unto you.”

Now that’s pretty darn interesting.

Ever since learning about the Satanic Golden Rule I’ve been able to use it productively when counseling teenagers. The Satanic Golden Rule is all about the immensely tempting revenge impulse we all sometimes feel and experience. It’s easy (and often gratifying) to give in to the powerful temptation to strike back at others whom you think have offended you. Whether it’s a gloomy and nasty grocery cashier or someone who’s consistently arrogant and self-righteous, it’s harder to take the high road and to treat others in ways we would like to be treated than it is to stoop to their level to give them a taste of their own medicine.

There are many flaws with the Satanic Golden Rule . . . but my favorite and the most useful for making a good point in counseling is the fact that, by definition, if you practice the Satanic Golden Rule, you’re giving your personal control over to other people. It’s like letting someone else steer your emotional ship. And to most my teenage clients this is a very aversive idea.

After talking about the Satanic Golden Rule many teenage clients are more interested in talking about how they can become leaders. . . leaders who are in control of their own emotions and who proactively treat others with respect.

An excellent side effect of all this is that it also inspires me to try harder to be proactively respectful, which helps me be and become a better captain of my own emotional ship.

Stuff Barry Says (and does)

This blog is in honor of my friend, Barry Johnson, who doesn’t read my blog. I met Barry in August of 1972. I was carrying my gym-clothes in a paper bag. Barry noticed, but never made fun of me to my face. That’s a good way to start a life-long friendship.

Barry turned 55 today. Whenever I see him he suggests book titles to me. This time his suggestion was, “55 and Suicidal.” This is Barry’s idea of an excellent self-help book title. He told me that the fact that there’s no confusing 55 with midlife (which remains possible at 50) makes 55 much more emotionally painful. He also told me that being 55 and past mid-life is liberating because basically his life is over and so he can say and do whatever he wants. And Barry is an expert in eating and so I think this statement had something to do with him being able to eat whatever he wants . . . which is what he has always done except for when he briefly lived in Montana and decided to face that experience by doing a Melon-only diet (Watermelon only one week, followed by Cantelope-only). Barry is no longer an advocate for either Montana or the Melon diet.

Barry has funny ideas. He’s single. He’s a biofeedback practitioner turned real estate agent. He’s a gun-toting liberal. Sometimes he starts snorting uncontrollably when he’s laughing hard.

I think Emerson or someone said that consistency was the hob-goblin of little minds. Barry has a big mind with room for contradiction. He’s also one of the kindest people I’ve ever known. He’s been one person I can count on to make terrible fun of me . . . which he typically does exactly when my ego needs deflating.

It feels like big-minded Barry has been my friend forever. One of my next life goals is to convince him to try a little exercise and a healthy diet. I’ve been doing this for a couple decades and failing, but “Hey Barry” if you’re out their reading this I’m writing this because I love having you as a friend and so you should start eating right and exercising to take care of my own selfish needs.

There. That should do it.

Happy 55th Birthday Barry. Live long and prosper.

Author, Speaker, University of Montana Professor