Tag Archives: assessment

Suicide Myths — Part Two

From M 2019 Spring

This is part two of my “Four Suicide Myths” blog post. If you read part one, you probably noticed that it ended abruptly. Apparently, that’s how I do two-part blog posts. Thinking back, I should have added something like, “end of part one.” 

And so, as an introduction, here’s the beginning of part two . . .

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.” Additionally, the rates of suicidal thinking among high school and college students is so high (estimates of 20-40% annual incidence) that it’s more appropriate to label suicidal thoughts as common, rather than a sign of deviance or illness.

Edwin Shneidman—the American “Father” of suicidology—denied a relationship between suicide and so-called mental illness in the 1973 Encyclopedia Britannica, stating succinctly:

“Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although . . . it has often been so treated in Western and other cultures).”

A recent report from the U.S. Centers for Disease Control (CDC) supported Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder. Keep in mind that the CDC wasn’t focusing on people who think about or attempt suicide; their study focused only on individuals who died by suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), meet diagnostic criteria for a mental disorder.  As one of my mentors used to say, “Having the thought of suicide is not dangerous and is not the problem.”

Truth #2: Suicidal thoughts are not—in and of themselves—a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress.

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

In 1995, renowned suicidologist, Robert Litman wrote:

At present it is impossible to predict accurately any person’s suicide. Sophisticated statistical models . . . and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient commits suicide while nine other equally depressed and equally suicidal patients do not, I answer, “I don’t know.” (p. 135)

Litman’s comments remain true today. Part of the problem stems from the fact that suicide is what is referred to as a low base rate event. When something occurs at a low base rate, it becomes mathematically very difficult to predict. Suicide is a prime example of a low base rate event. According to the CDC, in 2017, only about 14 of every 100,000 citizens died by suicide.

Imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 14 of the 100,000 fans will die by suicide over the next 365 days.

A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that every one of the 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide) and ask them to leave the stadium. Now you’re down to identifying which 14 of 15,000 will die by suicide.

For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.

At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive psychological treatment for the remaining 7,500 people. However, many of the fans will refuse treatment, including some of whom will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.

To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 14 individuals who will die by suicide over the next year. All this points to the magnitude of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people some of the time.

Truth #4: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research doesn’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, odds are, in the vast majority of cases, you won’t be able to efficiently predict or prevent suicide attempts or suicide deaths.

Myth #4: Suicide prevention and intervention should focus on eliminating suicidal thoughts.

Logical analysis implies that if suicidal thoughts within an individual are eliminated, then suicide will be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy? The first reason is because most people who think about suicide never make a suicide attempt. But that’s only the tip of the iceberg.

After his son died by suicide, Rick Warren, a famous pastor and author, created a Youtube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads, “If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!”

Although over 1,000 viewers clicked on the “thumbs up” sign for the video, there were 535 comments; these comments mostly pushed back on Pastor Warren’s well-intended message. Examples included:

  • Are you kidding me??? You’ve clearly never been suicidal or really depressed.
  • To say “Suicide is a permanent solution to a temporary problem” is like saying: “You couldn’t possibly have suffered long enough, even if you’ve suffered your entire life from many, many issues.”
  • This is extremely disheartening. With all due respect. Pastor, you just don’t get it.

Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, most of us try to use rational persuasion to encourage individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called psychological reactance helps explain why rational persuasion—even when well-intended—rarely makes for an effective intervention.

While working with chronically suicidal patients for over two decades, Dr. Marsha Linehan of the University of Washington made an important discovery: when psychotherapists try to get their patients to stop thinking about suicide, the opposite usually happens—the patients become more suicidal.

Linehan’s discovery has played out in my clinical practice. Nearly every time I’ve actively pushed clients to stop thinking about suicide—using various psychological ploys and techniques—my efforts have backfired.

Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective.

Starting Over

Individuals who are suicidal are complex, unique, and in deep distress. Judging them as ill is unhelpful. Believing that we can successfully predict and prevent suicide borders on delusional. Direct persuasion usually backfires. Letting go of the four common suicide myths might make you feel nervous. At least they provided guidance for action, right? But just like having the female on top to prevent pregnancy, clinging to unhelpful myths won’t, in the end, be effective. How do we start over? Where do we go from here?

All solutions—or at least most of them—begin with a clear understanding of the problem. As someone who has worked directly with suicidal individuals for decades, there’s no better person to start us on the journey toward a deeper understanding of suicide than Dr. Marsha Linehan.

Dr. Linehan is the developer of dialectical behavior therapy (DBT for short). DBT is widely hailed as the most effective evidence-based approach for working with chronically suicidal patients. To help her students at the University of Washington better understand the dynamics of suicide, Dr. Linehan begins her teaching with this story:

The suicidal person [is] trapped in a small, dark room with no windows and high walls (in my mind always with stark white walls reaching very, very high). The room is excruciatingly painful. The person searches for a door out to a life worth living but, alas, cannot find it. Scratching and clawing on the walls does no good. Screaming and banging brings no help. Falling to the floor and trying to shut down and feel nothing gives no relief. Praying to God and all the saints one knows brings no salvation. The only door out the individual can find is the door to death. The task of the therapist in this situation, as I always tell my clients also, is to somehow find a way to get into the room with the person, to see the person’s world from his or her point of view; to get inside the person, so to speak, and then together search again for that door to life that the therapist knows must be there.

Efforts to understand someone else’s reality are destined to fall short. You can’t always get it right, but that’s okay, because empathy is more about being with and feeling with others, than it is about perfectly understanding them. Trying to understand the inner world of others is an act of courage and compassion. Thus, our next step is to suspend judgment and begin our descent into that small, dark room with no windows.

The Clinical Interview as an Assessment Tool

Chair

The following is another excerpt from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. This excerpt focuses on ways in which clinical interviews are used as assessment tools. The full chapter is forthcoming in the Cambridge Handbook of Clinical Assessment and Diagnosis. For more (much more) information on clinical interviewing, see our textbook, creatively titled, Clinical Interviewing, now in its 6th edition. If you’re a professor or college instructor, you can get a free evaluation copy here: https://www.wiley.com/en-us/Clinical+Interviewing%2C+6th+Edition-p-9781119215585

The clinical interview often involves more assessment and less intervention. Interviewing assessment protocols or procedures may not be limited to initial interviews; they can be woven into longer term assessment or therapy encounters. Allen Frances (2013), chair of the DSM-IV task force, recommended that clinicians “be patient,” because accurate psychiatric diagnosis may take “five minutes. . .”  “five hours. . .”  “five months, or even five years” (p. 10).

Four common assessment interviewing procedures are discussed next: (1) the intake interview, (2) the psychodiagnostic interview, (4) mental status examinations, and (4) suicide assessment interviewing.

The Intake Interview

The intake interview is perhaps the most ubiquitous clinical interview; it may be referred to as the initial interview, the first interview, or the psychiatric interview. What follows is an atheoretical intake interview model, along with examples of how theoretical models emphasize or ignore specific interview content.

Broadly speaking, intake interviews focus on three assessment areas: (1) presenting problem, (2) psychosocial history, and (3) current situation and functioning. The manner in which clinicians pursue these goals varies greatly. Exploring the client’s presenting problem could involve a structured diagnostic interview, generation and analysis of a problem list, or clients free associating to their presenting problem. Similarly, the psychosocial history can be a cursory glimpse at past relationships and medical history or a rich and extended examination of the client’s childhood. Gathering information about the client’s current situation and functioning can range from an informal query about the client’s typical day to a formal mental status examination (Yalom, 2002).

Psychodiagnostic Interviewing

The psychodiagnostic interview is a variant of the intake interview. For mental health professionals who embrace the medical model, initial interviews are often diagnostic interviews. The purpose of a psychodiagnostic interview is to establish a psychiatric diagnosis. In turn, the purpose of psychiatric diagnosis is to describe the client’s current condition, prognosis, and guide treatment.

Psychodiagnostic interviewing is controversial. Some clinicians view it as essential to treatment planning and positive treatment outcomes (Frances, 2013). Others view it in ways similar to Carl Rogers (1957), who famously wrote, “I am forced to the conclusion that … diagnostic knowledge is not essential to psychotherapy. It may even be … a colossal waste of time” (pp. 102–103). As with many polarized issues, it can be useful to take a moderate position, recognizing the potential benefits and liabilities of diagnostic interviewing. Benefits include standardization, a clear diagnostic focus, and identification of psychiatric conditions to facilitate clinical research and treatment (Lilienfeld, Smith, & Watts, 2013). Liabilities include extensive training required, substantial time for administration, excess structure and rigidity that restrain experienced clinicians, and questionable reliability and validity, especially in real-world clinical settings (Sommers-Flanagan & Sommers-Flanagan, 2017).

Clinicians who are pursuing diagnostic information may integrate structured or semi-structured diagnostic interviews into an intake process. The research literature is replete with structured and semi-structured diagnostic interviews. Clinicians can choose from broad and comprehensive protocols (e.g., the Structured Clinical Interview for DSM-5 Disorders – Clinician Version; First et al., 2016) to questionnaires focusing on a single diagnosis (e.g., Autism Diagnostic Interview – Revised; Zander et al., 2017). Additionally, some diagnostic interviewing protocols are designed for research purposes, while others help clinicians attain greater diagnostic reliability and validity. Later in this chapter we focus on psychodiagnostic interviewing reliability and validity.

The Mental Status Examination

The MSE is a semi-structured interview protocol. MSEs are used to organize, assess, and communicate information about clients’ current mental state (Sommers-Flanagan, 2016; Strub & Black, 1977). To achieve this goal, some clinicians administer a highly structured Mini-Mental State Evaluation (MMSE; Folstein, Folstein, & McHugh, 1975), while others conduct a relatively unstructured assessment interview but then organize their observations into a short mental status report. There are also clinicians who, perhaps in the spirit of Piaget’s semi-clinical interviews, combine the best of both worlds by integrating a few structured MSE questions into a less structured interview process (Sommers-Flanagan & Sommers-Flanagan, 2017).

Although the MSE involves collecting data on diagnostic symptoms, it is not a psychodiagnostic interview. Instead, clinicians collect symptom-related data to communicate information to colleagues about client mental status. Sometimes MSEs are conducted daily or hourly. MSEs are commonly used within medical settings. Knowledge of diagnostic terminology and symptoms is a prerequisite to conducting and reporting on mental status.

Introducing the MSE. When administering an MSE, an explanation or role induction is needed. A clinician might state, “In a few minutes, I’ll start a more formal method of getting … to know you. This process involves me asking you a variety of interesting questions so that I can understand a little more about how your brain works” (Sommers-Flanagan & Sommers-Flanagan, 2017, pp. 580–581).

Common MSE domains. Depending on setting and clinician factors, the MSE may focus on neurological responses or psychiatric symptoms. Nine common domains included in a psychiatric-symptom oriented MSE are

  1. Appearance
  2. Behavior/psychomotor activity
  3. Attitude toward examiner (interviewer)
  4. Affect and mood
  5. Speech and thought
  6. Perceptual disturbances
  7. Orientation and consciousness
  8. Memory and intelligence
  9. Reliability, judgment, and insight.

Given that all assessment processes include error and bias, mental status examiners should base their reports on direct observations and minimize interpretive statements. Special care to cross-check conclusive statements is necessary, especially when writing about clients who are members of traditionally oppressed minority groups (Sommers-Flanagan & Sommers-Flanagan, 2017). Additionally, using multiple assessment data sources (aka triangulation; see Using multiple (collateral) data sources) is essential in situations where patients may have memory problems (e.g., confabulation) or be motivated to over- or underreport symptoms (Suhr, 2015).

MSE reports. MSE reports are typically limited to one paragraph or one page. The content of an MSE report focuses specifically on the previously listed nine domains. Each domain is addressed directly with at least one statement.

Suicide Assessment Interviewing

The clinical interview is the gold standard for suicide assessment and intervention (Sommers-Flanagan, 2018). This statement is true, despite the fact that suicide assessment interviewing is not a particularly reliable or valid method for predicting death by suicide (Large & Ryan, 2014). The problem is that, although standardized written assessments exist, they are not a stand-alone means for predicting or intervening with clients who present with suicide ideation. In every case, when clients endorse suicide ideation on a standardized questionnaire or scale, a clinical interview follow-up is essential. Although other assessment approaches exist, they are only supplementary to the clinical interview. Key principles for conducting suicide assessment interviews are summarized below.

Contemporary suicide assessment principles. Historically, suicide assessment interviewing involved a mental health professional conducting a systematic suicide risk assessment. Over the past two decades, this process has changed considerably. Now, rather than taking an authoritative stance, mental health professionals seek to establish an empathic and collaborative relationship with clients who are suicidal (Jobes, 2016). Also, rather than assuming that suicide ideation indicates psychopathology or suicide risk, clinicians frame suicide ideation as a communication of client distress. Finally, instead of focusing on risk factors and suicide prediction, mental health professionals gather information pertaining to eight superordinate suicide dimensions or drivers and then work with suicidal clients to address these dimensions through a collaborative and therapeutic safety planning process (Jobes, 2016). The eight superordinate suicide dimensions include:

  • Unbearable emotional or psychological distress: Unbearable distress can involve one or many trauma, loss, or emotionally disturbing experiences.
  • Problem-solving impairments: Suicide theory and empirical evidence both point to ways in which depressive states can reduce client problem-solving abilities.
  • Interpersonal disconnection, isolation, or feelings of being a social burden: Joiner (2005) has posited that thwarted belongingness and perceiving oneself as a burden contributes to suicidal conditions.
  • Arousal or agitation: Many different physiological states can increase arousal/agitation and push clients toward using suicide as a solution to their unbearable distress.
  • Hopelessness: Hopelessness is a cognitive variable linked to suicide risk. It can also contribute to problem-solving impairments.
  • Suicide intent and plan: Although suicide ideation is a poor predictor of suicide, when ideation is accompanied by an active suicide plan and suicide intent, the potential of death by suicide is magnified.
  • Desensitization to physical pain and thoughts of death: Fear of death and aversion to physical pain are natural suicide deterrents; when clients lose their fear of death or become desensitized to pain, suicide behaviors can increase.
  • Access to firearms: Availability of a lethal means, in general, and access to firearms, in particular, substantially increase suicide risk.

(For additional information on suicide assessment interviewing and the eight suicide dimensions, see other posts on this site).

Five Stages of a Clinical Interview

Baseball Seager

The following is a preview from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. The full chapter will be in the Cambridge Handbook of Clinical Assessment and Diagnosis . . . which is coming out soon.

The clinical interview is a fundamental assessment and intervention procedure that mental and behavioral health professionals learn and apply throughout their careers. Psychotherapists across all theoretical orientations, professional disciplines, and treatment settings employ different interviewing skills, including, but not limited to, nondirective listening, questioning, confrontation, interpretation, immediacy, and psychoeducation. As a process, the clinical interview functions as an assessment (e.g., neuropsychological or forensic examinations) or signals the initiation of counseling or psychotherapy. Either way, clinical interviewing involves formal or informal assessment.

Clinical interviewing is dynamic and flexible; every interview is a unique interpersonal interaction, with interviewers integrating cultural awareness, knowledge, and skills, as needed. It is difficult to imagine how clinicians could begin treatment without an initial clinical interview. In fact, clinicians who do not have competence in using clinical interviewing as a means to initiate and inform treatment would likely be considered unethical (Welfel, 2016).

Clinical interviewing has been defined as

a complex and multidimensional interpersonal process that occurs between a professional service provider and client [or patient]. The primary goals are (1) assessment and (2) helping. To achieve these goals, individual clinicians may emphasize structured diagnostic questioning, spontaneous and collaborative talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a [therapeutic relationship], case formulation, and treatment plan” (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 6)

A Generic Clinical Interviewing Model

All clinical interviews follow a common process or outline. Shea (1998) offered a generic or atheoretical model, including five stages: (1) introduction, (2) opening, (3) body, (4) closing, and (5) termination. Each stage includes specific relational and technical tasks.

Introduction

The introduction stage begins at first contact. An introduction can occur via telephone, online, or when prospective clients read information about their therapist (e.g., online descriptions, informed consents, etc.). Client expectations, role induction, first impressions, and initial rapport-building are central issues and activities.

First impressions, whether developed through informed consent paperwork or initial greetings, can exert powerful influences on interview process and clinical outcomes. Mental health professionals who engage clients in ways that are respectful and culturally sensitive are likely to facilitate trust and collaboration, consequently resulting in more reliable and valid assessment data (Ganzini et al., 2013). Technical strategies include authentic opening statements that invite collaboration. For example, the clinician might say something like, “I’m looking forward to getting to know you better” and “I hope you’ll feel comfortable asking me whatever questions you like as we talk together today.” Using friendliness and small talk can be especially important to connecting with diverse clients (Hays, 2016; Sue & Sue, 2016). The introduction stage also includes discussions of (1) confidentiality, (2) therapist theoretical orientation, and (3) role induction (e.g., “Today I’ll be doing a diagnostic interview with you. That means I’ll be asking lots of questions. My goal is to better understand what’s been troubling you.”). The introduction ends when clinicians shift from paperwork and small talk to a focused inquiry into the client’s problems or goals.

Opening

The opening provides an initial focus. Most mental health practitioners begin clinical assessments by asking something like, “What concerns bring you to counseling today?” This question guides clients toward describing their presenting problem (i.e., psychiatrists refer to this as the “chief complaint”). Clinicians should be aware that opening with questions that are more social (e.g., “How are you today?” or “How was your week?”) prompt clients in ways that can unintentionally facilitate a less focused and more rambling opening stage. Similarly, beginning with direct questioning before establishing rapport and trust can elicit defensiveness and dissembling (Shea, 1998).

Many contemporary therapists prefer opening statements or questions with positive wording. For example, rather than asking about problems, therapists might ask, “What are your goals for our meeting today?” For clients with a diverse or minority identity, cultural adaptations may be needed to increase client comfort and make certain that opening questions are culturally appropriate and relevant. When focusing on diagnostic assessment and using a structured or semi-structured interview protocol, the formal opening statement may be scripted or geared toward obtaining an overview of potential psychiatric symptoms (e.g., “Does anyone in your family have a history of mental health problems?”; Tolin et al., 2018, p. 3).

Body

The interview purpose governs what happens during the body stage. If the purpose is to collect information pertaining to psychiatric diagnosis, the body includes diagnostic-focused questions. In contrast, if the purpose is to initiate psychotherapy, the focus could quickly turn toward the history of the problem and what specific behaviors, people, and experiences (including previous therapy) clients have found more or less helpful.

When the interview purpose is assessment, the body stage focuses on information gathering. Clinicians actively question clients about distressing symptoms, including their frequency, duration, intensity, and quality. During structured interviews, specific question protocols are followed. These protocols are designed to help clinicians stay focused and systematically collect reliable and valid assessment data.

Closing

As the interview progresses, it is the clinician’s responsibility to organize and close the session in ways that assure there is adequate time to accomplish the primary interview goals. Tasks and activities linked to the closing include (1) providing support and reassurance for clients, (2) returning to role induction and client expectations, (3) summarizing crucial themes and issues, (4) providing an early case formulation or mental disorder diagnosis, (5) instilling hope, and, as needed, (6) focusing on future homework, future sessions, and scheduling (Sommers-Flanagan & Sommers-Flanagan, 2017).

Termination

Termination involves ending the session and parting ways. The termination stage requires excellent time management skills; it also requires intentional sensitivity and responsiveness to how clients might react to endings in general or leaving the therapy office in particular. Dealing with termination can be challenging. Often, at the end of an initial session, clinicians will not have enough information to establish a diagnosis. When diagnostic uncertainty exists, clinicians may need to continue gathering information about client symptoms during a second or third session. Including collateral informants to triangulate diagnostic information may be useful or necessary.

See the 6th edition of Clinical Interviewing for MUCH more on this topic: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_1?crid=1J46F6YFDV7XG&keywords=clinical+interviewing+6th+edition+sommers-flanagan&qid=1561646075&s=books&sprefix=clinical+inter%2Cstripbooks%2C242&sr=1-1

Why You Should Open with a Focus on the Negative When Using a Strength-Based Suicide Treatment Model

Keno Horse

I’m working on a book manuscript tentatively titled something like: Strength-Based Suicide Assessment and Treatment. As I do more work and professional training in this area, I’m struck by the natural dialectic involved in the whole area of suicide (I’m sure Marsha Linehan discovered this long ago).

One dialectic on my mind today involves the fact that although I’m calling the approach that I’m writing about “Strength-Based,” I often (but not always) advise clinicians to open their sessions with a focus on negative distress. The following excerpt takes a bit of content from my 7.5 hour (3-part) published video with Psychotherapy.net and explains my rationale for opening a session with a focus on negative or painful emotions. You can access the 3-part training video here: https://www.psychotherapy.net/video/suicidal-clients-series

Here’s the case example:

In the following excerpt, I’m working with Kennedy, a 15-year-old girl whose parents referred her to me for suicide ideation (see https://www.psychotherapy.net/video/suicidal-clients-series, Sommers-Flanagan, 2018). Although I might meet with her parents first, or with the whole family, in this case I chose to start therapy with her as an individual. My opening exchange with Kennedy is important because, in contrast to what you might expect from a “strength-based” approach, my focus with her is distinctly negative. Pay close attention to the italicized words and [bracketed explanation].

John:  Kennedy, thank you for meeting with me. Let me just tell you what I know, okay, because I know that you’re not exactly excited to be here. But the thing is that I know that your parents have said you’ve been talking about suicide off and on for a little while, and so they wanted me to talk with you. [I already know that suicide ideation is an issue with Kennedy, so I share that immediately. If I pretend that I don’t already know about her and her situation, it will adversely affect our rapport. This is a basic principle for working with teens, but also true for adults: Lead with a statement of what you know . . . and be clear about what you don’t know.]

And I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so I guess if you’re even willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is that you’re feeling? [You’ll notice that my opening question has a negative focus. The reason I’m starting with a question that focuses on Kennedy’s negative affect and pulls for what makes her feel bad or sad or miserable is because (a) I want to start with Kennedy’s emotional distress, because that’s what brings her to therapy, and (b) I want to immediately begin linking her emotional distress to situations or experiences that trigger her distress. By doing this, I’m focusing on the presumptive primary treatment goal (according to Shneidman) for all clients who are suicidal, and that is to reduce the perceived intolerable or excruciating emotional distress. In Kennedy’s case, one of my very first treatment targets is to reduce the frequency and intensity of whatever it is that’s triggering Kennedy’s suicide ideation. We’ll get to the positive, strength-based stuff later.]

Kennedy: I think I’m just like really busy every day. I am in volleyball, and I got a lot of homework, and I don’t get a lot of sleep. So, it’s really stressful getting up early, and my parents are always fighting, and sometimes I miss the bus, and they don’t want to drive me. So, I have to call one of my older friends to drive me, and sometimes I’m late, and I just – it’s stressful, and the teachers get mad, but it’s not my fault.

John:   Yeah. So, you’ve got some stress piling up, volleyball, school, sometimes being late, and your parents arguing. Of those, which one adds the most misery into your life? [Again, my focus is purposefully on the negative. I want to know what adds the most misery to Kennedy’s life so that I can work with her and her family or her and her school to decrease the stimulus or trigger for her misery.]

Kennedy: I think being at home is the hardest. In volleyball at least I find some joy. Like I like enjoy being on the court and playing with my team. They’re there to lift me up. But like my parents, I don’t like being at home.

John:  Okay. What do you hate about it? [When Kennedy says, “I don’t like being at home” she’s not providing me with specific information about the trigger for her distress, so I continue with that focus and stay with the negative and use a word (hate) that I think is a good match for how a teenage girl might sometimes feel about being with her family.]

Kennedy: I just – they’re always fighting. Sometimes my dad will leave, and my mom cries, and I’ll cry. And he’s just mean, and she’s mean, and they’re both mean to each other. And I just lock myself in my room.

John:   Yeah. So, even as I listen to you talk, it feels like this is a – just being around them – I don’t know what the feeling is, maybe of just being alone. Like they’re fighting, and you retreat to your room. Any other feelings coming up when that happens? [Although I’m trying to tune into specific feeling words to link to what’s happening for Kennedy, I’m also being tentative and vague and wanting to collaboratively explore the right words to use with Kennedy.]

Kennedy: I don’t know. Just sometimes I don’t feel like – I don’t feel like I have a home, or my family is not there for me, and sometimes I just don’t feel like living anymore. [Kennedy uses the term “feel like” which often is a signal that she’s talking about a cognition and not an emotion. For example, “I don’t feel like I have a home” is likely more of a cognition that leaves her with an emotion like sadness. But it’s too soon to be that emotionally nuanced with Kennedy and the important part of what she’s saying is that there’s a pattern that’s something like this: her parents’ fighting triggers a cognition, that triggers an unspecified emotion, and that triggers the cognition of “I just don’t feel like living anymore.”]

John:   Yeah. So, there are times when the family stuff feels so bad, that’s when you start to think about suicide?

Kennedy: Yeah.

Using Shneidman’s (1980) model to guide my initial interactions with Kennedy leads me to focus on her immediate emotional distress and the triggers for her distress. Exploring her distress and the triggers takes me to an early treatment plan (that will likely be revised and refined).

  1. I will focus on Kennedy’s immediate distress and collaboratively work with her on a plan to reduce her distress and create more positive affect.
  2. I will focus on specific situational variables that trigger Kennedy’s suicide ideation. Part of the treatment plan is likely to involve her parents and to try to get them to stop their intense “fighting” in her presence.
  3. As I aim toward distress reduction and reducing or eliminating the distress trigger, I will keep in mind that—like most teenagers—it may be very difficult for me to get Kennedy to agree to let me work directly with her parents on their fighting. Getting Kennedy on board for an intervention with her parents will test my therapeutic and relational skills.

While I’m working on this next book, I’ll be posting excerpts like this. As always, I would love your feedback and input on this content. Please post comments here, or email me directly at: john.sf@mso.umt.edu.

What Is a Strength-Based Approach to Suicide Prevention?

Sommers FB 44

Suicide—as a thought, word, or action—usually triggers fear and judgment. Even though suicidal thoughts are common and suicidal behaviors have been part of humanity from as far back as anyone can recall, to think or talk of suicide is saturated with shame and judgment. A strength-based model for suicide prevention is about shifting attitudes toward suicide from negative judgment to compassion and lovingkindness.

Most people who think about suicide are sensitive, intelligent, and self-critical. Typically, they’re judging themselves in negative ways; sometimes they experience self-hatred. All this adds up to the main proposition underlying a strength-based approach to suicide prevention: Because individuals who feel suicidal are already burying themselves in harsh judgments and negativity, what they need from others is empathy for their pain, reassurance that suicidal thoughts are a nearly universal part of human experience, compassion, help for coping with their excruciating psychological distress, and a more or less relentless focus on the positive.

No More Mental Illness and No More Moral Shaming

In 1973, Edwin Shneidman, wrote the Encyclopedia Britannica’s definition of suicide: “Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality.” Shneidman—often referred to as the father of suicidology (the study of suicide)—capture two harsh judgments popularly linked to suicide: Mental or moral illness. As advocates for suicide prevention, we need to doggedly follow Shneidman’s lead, and show acceptance of the mental and moral condition of people experiencing suicidality.

I like this next quotation from Nanea Hoffman. I’m not sure it fits here, but because this post is about being strength-based when thinking and talking about suicide, and this is my blog and I can include what I want, here it is:

“None of us are getting out of here alive . . . so please stop treating yourself like an afterthought. Eat the delicious food. Walk in the sunshine. Jump in the ocean. Say the truth you’re carrying in your heart like hidden treasure. Be silly. Be kind. Be weird. There’s no time for anything else.” – Nanea Hoffman

Shame surrounding suicide has a long history. By 1000 B.C. most ancient city-states had criminalized suicide. People who died from suicide were sometimes dragged through the streets to enhance their shame and possibly as deterrence for others. Around 400 A.D., Saint Augustine declared suicide an unrepentable sin. I’m not quite sure how that works because I’m guessing that Christian theology would hold up God as the authority on what’s repentable and what’s not repentable.

Contemporary suicide-related policies continue to link shame and suicide. When students die from suicide, many U.S. schools follow a “no memorializing” policy. In New Zealand, the media is prohibited from using the word suicide when reporting on suicide deaths. Most families, when struggling to write obituaries for family members who died by suicide, replace the word suicide with “died suddenly” or some other vague explanation. In an online article, Charlotte Maya wrote of the first time she was able to speak of her husband’s suicide:

“The first time I spoke publicly was about a year and a half after Sam’s death. In many ways, I think Sam would have been appalled. After all, he did not speak a word of his struggles out loud – not to a therapist, not to his friends, not to me. There is so much shame.”

Charlotte is right; there is so much shame. To avoid shame, many people, institutions, and nations have decided that—like Lord Voldemort in the Harry Potter series—suicide is the thing that must not be named.

But it should be named; if we don’t talk about it, the shame linked to suicide grows more powerful, more frightening, and less well understood. It should be named because, hundreds of thousands of people around the world are dying by suicide every year, perhaps dying in shame, perhaps dying unnecessarily, and always leaving loved ones behind who pick up on the theme of shame and begin experiencing it themselves. If we don’t talk openly about suicide, we cannot address it effectively.

Shaming people for thinking about suicide, or for making a suicide attempt, or for completing suicide, magnifies the problem. Shaming people for their suicidal thoughts only makes them less likely to speak openly about their thoughts. And, as in the case of Charlotte Maya’s husband, remaining quiet about emotional pain is linked to tragic outcomes. When people who are suicidal shutter themselves in their private worlds, the suicidal pain and distress doesn’t diminish or evaporate; instead, being alone with suicidal thoughts usually deepens hopelessness and grows desperation, both of which contribute directly to death by suicide.

Shaming individuals who are suicidal is like pouring fuel on an open fire. Suicidal people already feel immense shame. There’s no need to add more. Besides, shaming isn’t an effective deterrent. Further, as I’ll elaborate on later, suicidal thoughts aren’t primarily about death anyway. If our goal is to save lives, there’s a different and more useful emotion to link with suicide.

Instead of shame, the word suicide should evoke compassion—compassion for people who were or are so distressed that they have contemplated or completed suicide; compassion for people who lost someone they loved to suicide; compassion for ourselves, during times when we’re in psychological pain and naturally have thoughts about suicide.

I’ll be writing more about this in the future and so I’ll summarize here. What people who are suicidal need from others includes:

  • Empathy for their pain
  • Reassurance that suicidal thoughts are a nearly universal part of human experience
  • Compassion
  • Help for coping with their excruciating psychological distress
  • A more or less relentless focus on the positive (to help counter their feelings of hopelessness)

Last night I had a chance to engage in a delightful discussion of the strength-based approach with a small group of amazing people at Big Sky, Montana. Thanks to Robin and Jacque for setting that up. As a part of our time together, I flipped through a set of powerpoints. Here are the powerpoints, in case you’re interested: Big Sky Public Lecture 2019

Advances in Suicide Assessment and Treatment . . . just published in the Jubilee Edition of Psychology Aotearoa

Ocean View

Here’s the view from New Zealand.

The professional journal, Psychology Aotearoa is the flagship publication of the New Zealand Psychological Society. Just yesterday I received a copy of the Jubilee Edition of the journal. I’ve got a brief article on pp. 76-80, but the whole journal is an interesting glimpse of psychology, psychotherapy, and counseling at an international level. Here’s the pdf: 2018 November JSF New Zealand Pub

Last Call for the Suicide Assessment and Intervention Psychotherapy.net Video Training

Hi All.

Below is the link for the $139 deal for the 7.5 hour Assessment and Intervention with Suicidal Clients training video with Psychotherapy.net.

Please share this information with other professionals who might want or need to sharpen their skills for working with clients who are or might become suicidal. This is a hard topic and I hope this resource can help clinicians feel more confident and competent in their suicide assessment and intervention skills.

https://academy.psychotherapy.net/p/suicide-promo?utm_source=ActiveCampaign&utm_medium=email&utm_content=LAST+CHANCE%3A+Suicide+Assessment+and+Intervention&utm_campaign=suicide+course+email%233