Tag Archives: prevention

The Case Against Zero Suicide

SunsetI’ve been trying for the past year to find a way to say this nicely. Finally, I discovered a recent article in the Journal of the American Medical Association (JAMA) that says what I want to say—at least in part—in a more professional tone. The articles is “Implications of Zero Suicide for Suicide Prevention Research.” Spoiler alert, the authors, Dominic Sisti, Ph.D. and Stephen Joffe, M.D. end their article with the following sentence: “To demonstrate which interventions are effective for reducing the suicide epidemic, it is necessary to let go of the belief that every suicide is preventable.” For their whole article, go to: https://jamanetwork.com/journals/jama/fullarticle/2706416?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=102318

I have no doubt that my views are more extreme that Drs Sisti and Joffe. They’re medical researchers, publishing in JAMA. But I was heartened by their article; it helped me feel less alone in my dislike for Zero Suicide. They inspired me to share some of my thoughts and writing on the topic.

That said, now I’m sharing an unpublished rant about Zero Suicide. Keep in mind that I’m in favor of suicide intervention and suicide prevention. I’ve even started a trade book proposal on the subject. But I’m not in favor of Zero Suicide. Here’s why:

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Last month I entered into a Twitter debate about Zero Suicide. It started and ended like most Twitter debates. We disagreed in the beginning. Then, after several passionate exchanges, we disagreed even more in the end.

The issue was Zero Suicide. Zero Suicide is a national suicide prevention campaign, healthcare philosophy, and comfortable delusion. In case you haven’t yet heard of Zero Suicide, there’s a Zero Suicide Academy, Zero Suicide ToolKit, Zero Suicide Community, and several websites orienting people to the Zero Suicide Initiative. As a pragmatic mental health professional and sentient human being, I’m completely in favor of suicide prevention. I’m in favor of suicide prevention because many people who think about suicide are in great psychological pain, and if that pain can be addressed, then their suicide wishes often can abate. I also support much of what the various Zero Suicide Initiative involves. However, as a behavioral scientist and someone who has regular contact with other humans, I consider Zero Suicide to be a ridiculous philosophy and a DUMB goal.

Zero Suicide is a DUMB goal, principally because it’s the opposite of a SMART goal. You can find definitions of SMART goals all over the internet. SMART goals are commonly attributed to Peter Drucker—a renowned management consultant, Austrian immigrant, and author of 39 books. Drucker is commonly considered one of the most important thought leaders in business management. Using Drucker’s principles, back in 1981, George T. Doran published a paper in Management Review titled, There’s a S.M.A.R.T. way to write management’s goals and objectives. Although many variations exist, SMART goals are typically defined as:

S =  Specific

M = Measurable

A = Achievable or Assignable

R = Relevant or Realistic

T = Time-bound

Drucker and Doran were writing from a business management perspective, but smart goals are also intrinsic to psychotherapy. I won’t be going into the details here, but William Glasser and Robert Wubbolding, two renowned reality therapists, describe important variations of smart goals in psychotherapy. Put simply, the philosophy of Glasser and Wubbolding is simply common sense: “A goal should be within your control.” Put differently, if individuals or agencies identify goals that are dependent on other people’s behavior, then frustration and other problems will inevitably ensue.

Online resources for Zero Suicide are impressive. The breadth and volume of information will provide healthcare professionals with an excellent foundation for working with suicidal patients. For the most part, I have few objections to the quality and quantity of their online suicide prevention resources. Having these resources for healthcare professionals and the general public is important and fantastic. With a foundation of knowledge and informed action, it’s possible to prevent some, but not all suicides.

Despite its impressive array of information, Zero Suicide also has several shortcomings. For example, nowhere on their 66 item Zero Suicide Workforce Survey do they ask a question about having or holding empathy or compassion for suicidal patients. Empathy and compassion needs continual re-emphasis in suicide prevention. Why? Because patients, clients, and citizens who are suicidal, are also often experiencing depressive symptoms. All helpers and healthcare professionals should understand that empathic responding is the foundation of suicide intervention and prevention. Even further, one common depressive symptom is irritability. If irritability is present (along with depression and suicidal thoughts, when healthcare workers or others try to intervene with suicidal people—or persuade them to get help—the following pattern might emerge.

Gloria: I’m concerned about you and how you’re doing. “Have you been thinking about suicide?”

Sean: Yes. I think about it all the time.

Gloria: I want to tell you that there are some excellent resources available for people who are feeling suicidal.

Sean: I know that.

Gloria: Can I get you connected with a counselor here in town?

Sean: Not interested.

Gloria: But I want to be of some help to you, in some way.

Sean: I don’t want your pitiful help. I’m depressed and I’ve been thinking about suicide. I’ve been to counselors. Nothing helps.

Gloria: How about friends? Do you have some friends who might help and support you?

Sean: None of my friends care anymore.

Gloria: How about family?

Sean: My family has disowned me and I’ve disowned them.

Gloria: How about a church or community center? Lots of people get support at those places.

Sean: I can’t hardly get myself out of the house, so those are stupid ideas.

Gloria: Have you tried medications?

Sean: Medications just make me feel worse.

Gloria: How about exercise?

Sean: Seriously?

At this point in the conversation Gloria probably feels frustrated. She’s trying to help, but she can feel Sean resisting her efforts. Gloria is problem-solving, but Sean is feeling hopeless and isn’t able to engage in the problem-solving process. Sean has been through all these ideas in his head and in his depressive state of mind, he’s already rejected all these ideas as completely ineffective.

Next up, Gloria might up the ante by trying to get Sean to engage in logical thinking. She might say something like, “Suicide is a permanent solution to a temporary problem.” Having heard this logical ploy several times, Sean will be ready, “I’ve been living in misery for years. You might see the world as all happy and shit with your fancy shoes and Polly-Anna glasses on, but what I’m experiencing doesn’t feel temporary. I hate my life and I want to die.”

Even if Gloria is more saint-like than most, it will be difficult for her to sustain a helpful attitude toward Sean. She might try encouraging him to go to the hospital, but many suicidal people abhor the idea of hospitalization. Eventually, as Sean continues to insist that he’s suicidal, she might call for a county mental health professional to conduct an evaluation. If so, Sean may lie to the evaluator and say that he’s not imminently suicidal or the evaluator may decide Sean isn’t suicidal. Or, in the best case scenario, Sean may be hospitalized, but he also is likely to become very pissed off at Gloria, because he views her as usurping his personal rights and freedoms. In nearly every case, people like Sean are not likely to pause and thank Gloria for her suicide prevention efforts.

I could go on, but I’d probably just head further down this dark road. Instead, I’ll try to end with a few hopeful comments.

Suicide prevention is important, but it’s part of a strange dialectic. Sometimes, if we try hard to connect with someone and save them, we are fabulously successful. However, other times we try to connect and the person rejects us and suicide becomes even more likely. What’s the difference? I don’t know the perfect answer, but I’m pretty sure it involves collaboration and not coercion. I wish I had thought this up myself, but it’s something that suicidologists, researchers, and philosophers have known for millennia. On top of being fantastically unrealistic, zero suicide also smacks of coercion.

One of the best and forward thinking suicide intervention researchers is Marsha Linehan. You may have heard of her because she’s a University of Washington professor and developer of Dialectical Behavior Therapy. I’ll end with a rather amazing piece that she wrote. Take some time to read it and try to absorb the message. I think her story is all about being empathic and collaborative. Let me know if you think so too. Here are Marsha Linehan’s words, from the Foreword of a book titled, “Building a Therapeutic Alliance with the Suicidal Patient.”

I always tell my students a story about what it is like to work with suicidal individuals. In the story, I describe the suicidal person as 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.

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Assessment and Intervention with Suicidal Clients: A Brand New 7.5 Hour Video Training

Yellow Flowers

Suicide rates in the U.S. are at a 30 year high. Beginning in 2005, death by suicide in America began rising, and it hasn’t stopped, rising for 12 consecutive years.

Worldwide (and at the CDC) suicide rates are tracked using the number of deaths per 100,000 individuals. Although the raw numbers listed above are important (and startling), calculating deaths per 100,000 individuals provides a consistent per-capita measure that allows for systematic comparison of suicide rates across different populations, geographic regions, sexual identity, seasons of the year, and other important variables. For 2000, the CDC reported an unadjusted death by suicide rate of 10.4 persons per 100,000. For 2016, they reported 13.7 suicides per 100,000 Americans. This represents a 31.7% increase over 16 years.

As suicide rates have risen, federal, state, and local officials haven’t been idly standing by, wringing their hands, and wondering what to do. To the contrary, they’ve been actively engaged in suicide prevention. In 2001, the Surgeon General established the first National Suicide Prevention Strategy, revising it in 2012. All the while, there have been big pushes by federal and state governments, community organizations, schools, private businesses, and nonprofits to fund and promote suicide prevention programming. For the most part, the suicide specialists who run these programs are fantastic. They’re dedicated, knowledgeable, and passionate about saving lives. In addition to all the prevention programs available today, currently there are more evidence-based psychotherapies for suicidal people than ever before in the history of time.

But even in the face of these vigorous suicide prevention and intervention efforts, suicide rates continue to relentlessly rise . . . at an average rate of nearly 2% per year.

At this point it’s clear that prevention efforts may not have a direct influence on overall suicide rates. It’s tough to move the big needle that measures U.S. suicide rates. Some solutions may be more sociological and political. Of course, that doesn’t mean we should stop doing prevention. But, given the numbers, it’s important for us to try to find alternative methods for reducing and preventing suicide.

All this leads up to an announcement. Today, Psychotherapy.net published a three volume 7.5 hour video training titled, Assessment and Intervention with Suicidal Clients. This project was a collaboration between Rita, me, and Victor Yalom (along with his amazing staff at Psychotherapy.net). Although watching this video won’t automatically make suicide rates decrease, gaining awareness, knowledge, and skills on suicide assessment and intervention is one way counselors and psychotherapists can contribute to suicide prevention.

Psychotherapy.net is offering an introductory offer for the 7.5 hour video, with CEUs included. You can click here for details on the introductory offer and a sneak peek at the video.

I hope you find the video training helpful, and I look forward to hearing comments and feedback from you about how we can keep working together to help prevent suicide.

Talking with Clients about Suicidal Thoughts and Feelings

fortunes

Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.

Here’s a link to the text https://www.amazon.com/Clinical-Interviewing-Video-Resource-Center/dp/1119084237/ref=asap_bc?ie=UTF8

And here’s the excerpt:

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 se0em 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)

Three more examples of using a normalizing frame follow:

  • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
  • Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?
  • I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?

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 for you to sometimes think about suicide. 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.

 

IS PATH WARM – An Acronym to Guide Suicide Risk Assessment

Suicide Risk Factors, Acronyms, and the Evidence Base

[This is adapted from our forthcoming 5th edition of Clinical Interviewing]

In 2003, the American Association of Suicidology brought together a group of suicidologists to examine existing research and develop an evidence-based set of near-term signs or signals of immediate suicide intent and risk. These suicidologists came up with an acronym to help professionals and the public better anticipate and address heightened suicide risk. The acronym is: IS PATH WARM and it’s outlined below:

I = Ideation

S = Substance Use

P = Purposelessness

A = Anxiety

T = Trapped

H = Hopelessness

W = Withdrawal

A = Anger

R = Recklessness

M = Mood Change

        IS PATH WARM is typically referred to as evidence-based and, in fact, it was developed based on known risk factors and warning signs. Unfortunately, reminiscent of other acronyms used to help providers identify clients at high risk for suicide, in the only published study we could find that tested this acronym, IS PATH WARM failed to differentiate between genuine and simulated suicide notes (Lester, McSwain, & Gunn, 2011). Although this is hardly convincing evidence against the use of this acronym, it illustrates the inevitably humbling process of trying to predict or anticipate suicidal behavior. In conclusion, we encourage you to use the acronym in conjunction with the comprehensive and collaborative suicide assessment interviewing process described in our chapter in the Clinical Interviewing textbook. See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=sr_1_1?s=books&ie=UTF8&qid=1373655813&sr=1-1

After talking about IS PATH WARM in workshops over the past year or so, it seems important to emphasize that these “risk” factors are near-term risk factors. Other, very important longer-term risk factors, are not included. For example, previous attempts and clinical depression aren’t even on the list. And, although they include withdrawal, it seems that words like isolation or loneliness capture this dimension of risk at least as well.

The point of my criticism is to emphasize that even the best suicidologists on the planet struggle in their efforts to identify the most important immediate and longer-term suicide risk factors. This is primarily because suicide is nearly always unpredictable and one of the reasons that it’s unpredictable is because it occurs, on average in the U.S. in 13 people per 100,000. The other side of this dialectical coin is that, of course, we need to try to predict it and prevent it anyway.

You can check out more details about IS PATH WARM on many different internet sites, including a description of its origin provided by the American Association of Suicidology: http://www.suicidology.org/c/document_library/get_file?folderId=231&name=DLFE-598.pdf

Hey — We just got a grant to help prevent student assault at the University of Montana — Very cool.

I’m just writing a note here with a link to a news story with video about a new grant we just got in the Department of Counselor Education. Although it means more work, it also means more work for the good of the campus and for the good of women and men who suffer from assault. Yeah. I guess I’m saying this is a difficult topic, but it’s a place where there’s room to do lots of good stuff.

Here’s the link:

http://www.abcmontana.com/news/local/UM-Receives-300K-Grant-to-Prevent-Assaults-on-Campus-171259111.html

 

Sexual Assault Prevention at the University of Montana

Hey. I’ve got a letter to the editor in the Montana Kaimin out today. I even managed to work in some profanity appropriately geared to college students:). Check it out at: http://www.montanakaimin.com/opinion/letters-petsa-and-personal-responsibility-1.2906452#.UFtDo665W1w

The past two days (9/19 & 9/20) the Missoulian has run articles about an organization named Stop Abusive and Violent Environments (SAVE) and their criticism of the University of Montana required Personal Empowerment Through Self-Awareness (PETSA) video series designed to reduce and prevent the incidence of sexual assault. In particular, SAVE has complained that the U of M PETSA video series is not evidence-based. Being a scientist, this was of concern and so I immediately checked the SAVE website and discovered that SAVE is an organization that is not even REMOTELY related to evidence-based programming for sexual assault prevention or anything else. Their entire raison d’etre is to protect men from being falsely accused of intimate partner violence and sexual assault. Their website includes internal inconsistencies and videos that (unlike the PETSA series) have not been vetted by anyone other than the organization itself or other “believers” that men are somehow unfairly targeted.

SAVE claims to only be interested in the truth and scientific evidence. And they say U.S. law have evolved to the point that ANYONE can be convicted of sexual assault or intimate partner violence? Now, being male myself, I’m all about fair treatment for men and so this places me in a precarious position. If I oppose SAVE, am I opposing my own best interests?

Well . . . I’m going out on a limb here to say the SAVE folks are just plain wacky. They say they are only after the truth and that they support evidence-based approaches, but there is ABSOLUTELY NO EVIDENCE that changing laws to make it harder to prove sexual assault would result in a safer and less abusive environment in the U.S.

Although I think it’s important to acknowledge that false allegations happen and it’s important to address these false allegations through legal means, instead of sticking to the facts, SAVE relies on rhetoric and sensationalist debunking of a few incorrect statistics to lead people to believe that false reporting is the rule and not the exception. This phenomenon—when someone accuses someone else of perpetrating something they’re doing themselves—is referred to as projection.

My first big concern is that the Missoulian, in reporting this as news, has given SAVE a semblance of validity that it doesn’t deserve.

My second big concern is that the hard working creators of the PETSA videos will be criticized based on hysterical accusations from an organization using political rhetoric framed as science. Based on viewing 2 SAVE videos online and comparing them to the PETSA production it’s obvious that PETSA is vastly more evidence-based than SAVE – Talk about blatantly false allegations

http://www.montanakaimin.com/opinion/letters-petsa-and-personal-responsibility-1.2906452#.UFtDo665W1w