I spent my K-12 life at VSD #37. Today I’m back, doing a “Tough Kids” and suicide prevention workshop at Skyview H.S. Should be fun. Here are the handouts.
From 13 Reasons Why, to Chris Cornell’s recent death, issues pertaining to suicide have been in our face this month. This is no surprise. May (late spring in the Northern hemisphere) is nearly always the month with the highest suicide rates.
That’s why right now is an excellent time for some straight talk about suicide.
Suicide is an emotionally triggering topic that’s notoriously difficult to talk or write about. Most of us know people who have been suicidal. Some of us know people who have died by suicide. Still others who read this may be having suicidal thoughts in this moment, or may have made suicide attempts in the past. Talking and writing about suicide is unpleasant, but necessary.
Because suicide is difficult to talk about, myths and misconceptions flourish. Not talking (or writing) about suicide also makes it harder to keep tabs on the latest research. Sometimes, leading professional journals neglect publishing new articles on suicide for a decade or more. This brings me to my purpose. To bust a few stubborn suicide-related myths and provide a glimpse at recent research on suicide prevention.
Let’s begin with now.
It’s a beautiful green spring in Montana with brilliant white snow in the mountains. Despite this beauty and brilliance, suicide rates rise in the spring and early summer and drop in fall and winter. Most people think the opposite is true, but every year, late spring and early summer bring the highest rates. Why? There are theories, but unfortunately, “we don’t know” is the answer to this and many questions related to suicide. I’m starting with this misconception to illustrate how easy it is to get the even the simplest facts related to suicide completely wrong.
One of the most insidious and unhealthy myths about suicide is the promotion of the idea that suicidal thoughts and impulses represent deviance or indicate the presence of a mental disorder. Once again, although many think it so, this idea is also untrue. Suicidal thoughts are a normal and natural response to psychological distress and misery. Social disconnection (relationship break-ups, death of a loved one, or other relationship problems) also can trigger suicidal thoughts in so-called “normal” people.
Our entire culture needs to stop classifying suicidal thoughts as automatic deviance. At one point or another, most people contemplate suicide, at least briefly. That fact pretty much blows the whole idea of suicidal thoughts as deviance right out of the metaphorical water.
Suicidal thoughts can be associated with specific mental disorders, but they are not, in and of themselves, signs of a mental disorder. In a recent large scale study, it was reported that mental disorders and suicidal thoughts weren’t useful in determining which individuals would eventually make suicide attempts.
Believing that suicidal thoughts represent a mental disorder isn’t just untrue, it’s also unhelpful. People who are suicidal, don’t need the public or professionals to make them feel worse by implying that their suicidal thoughts represent some form of illness.
Another surprising research finding is that, in general, suicide warning signs and suicide risk factors are unhelpful. This is true despite the fact that following a death by suicide, one of the first messages you’ll hear in the media is how important it is to watch for specific suicide warning signs. Unfortunately, like many things related to suicide, this is both good and bad advice. It’s good advice in that it’s always important to notice when friends, family, coworkers, and strangers are in distress and to do what we can to be comforting. But it’s also bad advice. Pointing the public or professionals toward warning signs implies that scientifically-based warning signs exist. They don’t.
There’s no science that supports the usefulness of warning signs or risk factors. This may seem discouraging, but it shouldn’t, because it leads to ONE BIG EXCELLENT CONCLUSION. That is, we should all try to offer support, empathy, and compassion to everyone. The take-home message is, don’t wait to encounter a suicidal person to unleash your kind and compassionate side. You should be leading with that. All. The. Time.
Chew on this idea for a moment. We’re stuck. If we’re interested in suicide prevention (or in having healthy relationships), our best default response is to treat everyone with kindness, respect, and empathy. I understand that’s impossible and I understand that you may think there are some exceptions to universal compassion. But we should try to lead with kindness, respect, and empathy anyway.
A good thing about having a general philosophy of kindness and compassion is that it helps suicidal people trust you. It will be harder for them to conclude, “This person is just being nice because I’m suicidal.” Instead, you’ll be treating everyone with kindness and empathy simply because that’s the sort of world you’re creating around you.
Another common suicide myth is that asking about suicide might somehow put the idea of suicide into someone’s head. Not true. Most people who are suicidal feel relieved and appreciative if you ask them about it in a nonjudgmental way. And, if you ask someone and they aren’t suicidal, well, the point is that people are highly resilient. They’re not so fragile that posing a short inquiry about suicide suddenly becomes life threatening. The other point is that you should ask with kindness and compassion. Even better, you should normalize the question by saying something like, “It’s not unusual for someone in your situation to have thoughts about suicide. I’m wondering if you’ve been having suicidal thoughts?” Making a statement that normalizes (rather than pathologizes) suicidal thoughts can make it easier to for people to talk more openly . . . and when people who are suicidal are talking openly, it will be easier for you to be helpful.
As if it weren’t already hard enough, another thing that’s especially complex is that when people are contemplating suicide, they often have strong negative reactions to infringements on their personal freedoms. This is partly why telling someone, you shouldn’t or can’t choose suicide, is a bad idea. Well-meaning helpers who push people too hard away from suicidal thoughts and toward embracing life can come across as “not understanding.” This could trigger an oppositional response. The person you want to help might either stop talking about it (but keep thinking about it) or feel an urge to oppose all suicide prevention or intervention efforts.
It’s not unusual for suicidal people to feel interpersonally isolated, disconnected, or as if they’re a burden to family, friends, and society. This makes connecting with them all the more important. It’s unfortunate, but people experiencing depression can be rather irritable or unappreciative of your efforts to listen and help. When you express concern, they might say something nasty in response. If so, let go of your needs for feeling appreciated; listen and be supportive anyway.
People who are suicidal can have difficulty problem-solving in a way that reflects hopefulness. Who wouldn’t have trouble being optimistic after experiencing repeated misery? This is why it’s important to problem-solve WITH people who are suicidal. Don’t usurp their control; lend another perspective. Part of this perspective might be the simple message that suicide is always an alternative, but that it’s important to wait and try as many other alternatives as possible.
Often, the response to your problem-solving efforts will be something like, “I’ve tried everything and nothing helps.” Again, we need to understand that when someone is suicidal, this is how it feels! At this point, acknowledge that right now it feels like nothing could possibly help. But at the same time, it’s okay to say things like, “I want you to live.”
If you’re problem-solving with someone who is suicidal, it’s also important to be persistent. Try saying something like, “Let’s make a list of everything you’ve tried, starting with whatever was the worst and most unhelpful idea ever.” Starting with what was unhelpful can resonate with the person’s pessimistic mood and help you identify something that’s at least not the worst option on the planet.
Chris Cornell’s recent death by suicide is a reminder of how specific medications can sometimes increase an individual’s agitation and/or suicidal thoughts. He was taking Ativan (Lorazepam). Ativan is a benzodiazepine (like Xanax and Valium). IMHO (and the science supports this), benzos are very bad medications to use for anything other than very short-term treatment. The bottom line is that sometimes (not always) psychiatric medications are not a part of the suicide solution and can become part of the suicide problem.
Among other things, Thirteen Reasons Why is a reminder of how easy it is for people to feel tremendously guilty when someone dies by suicide. Twenty-six years later, I still feel guilt over the death of a boy with whom I was working. Was it my fault? Absolutely not. Do I still feel bad? Absolutely yes.
Death by suicide is a tragedy. I’m tempted to say that it’s always a tragedy, but I recognize that when it comes to humans and humanity, using the terms always and never is dicey.
Some individuals are living with what they experience as intolerable physical, psychological, or emotional suffering. For their loved ones it’s likely still a tragedy when they die by suicide, but is it a tragedy for them? It’s hard to rule out the possibility that death by suicide may represent solace for them.
Suicide is a very personal option on the palette of human choice. For example, I want people to live. I want to help them reduce their psychological pain, make positive relationship connections, and re-engage in activities they find meaningful. But even so, sometimes suicide happens anyway. This is deeply painful and the guilt can be enormous. If someone close to you dies by suicide or you’re feeling affected by any suicide-related event, please find someone to talk with. One of my former clients once said, “The mind is a terrible place . . . to go alone.” Find someone you can trust and share any dark thoughts you might be having. Deal with it. Don’t let your guilt and angst simmer.
To summarize, suicide rates are highest right now. Does that mean we can relax later? Of course not. Suicide risk factors and warning signs are mostly useless and so we should treat people with respect and compassion all the time. When needed, we should ask the suicide question directly and with a spirit of non-judgmental normality. When possible, we should help people with suicidal thoughts identify options that might move them toward feeling better, while acknowledging that suicide is an option. We need to remember that sometimes medications can make suicidality worse. Perfect prevention is impossible. Suicide may happen despite our best efforts. Dealing with guilt over a suicide takes time and requires support.
No one will be completely happy with the ideas I’ve written here. That’s good. Individual reactions to suicide issues are unique. If you want to argue with or improve on these ideas, feel free to engage in the conversation. Using an attitude of kindness and respect, let’s keep talking about suicide. Right now, that’s the best solution we have to our suicide problem. In fact, it may be the best solution we’ll ever have.
To check out my recent professional journal article in Professional Psychology, click here: SF and Shaw Suicide 2017
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.
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:
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.
This past year, Alexander Street Press has been filming and producing a number of Ted-like talks focusing on counseling and psychotherapy. These are 15 minute talks, followed by a short Q & A on the topic. Below is a transcript from a talk I gave this summer in their studio at Governor’s State University in Chicago. I’m posting this talk in honor of National Suicide Prevention Day. This talk, and another couple dozen talks, should be available later this year or early next year from Alexander Street Press: http://search.alexanderstreet.com/counseling-therapy
Here’s the transcript:
Ironically I usually feel happy when I’m asked to do a talk on suicide and then I start with great confidence. I think it’s because suicide is such an extremely important and stressful issue for mental health professionals. But once I dive into the content, I remember how difficult this topic is. During one public presentation a therapist-friend of mine walked out because, as he told me later, the content was hitting too close to home. So please, as you listen, take care of yourself and talk to friends and colleagues for support.
To be perfectly honest, I DON’T REALLY LIKE to talk about suicide, but I think it’s VERY IMPORTANT that we do so directly . . . with each other and with our clients . . . and so here we go.
Death by suicide is pretty rare. Every year, only about 1 in 10,000 Americans commit suicide.
Despite its low frequency, suicide is still a major social problem that affects nearly everyone in one way or another. Over the years you’ve probably heard of many famous people who died by suicide. Marilyn Monroe and Kurt Cobain are two prime examples.
Perhaps even more important is the problem of suicide attempts. About 10% of the human population has attempted suicide and about 20% report struggling with suicidal thoughts and impulses. In surveys of high school students about 50% report “thinking about suicide.”
To summarize what we know about suicide base rates we can say:
I. Death by suicide is infrequent
II. Suicide attempts are NOT infrequent. In fact, many people attempt suicide and then go on to lead happy and meaningful lives
III. Suicide ideation (thoughts) are common
IV. And this is what makes suicide prediction very difficult, because it occurs so infrequently, but this is also what makes suicide prevention very necessary.
In 1991, I worked with a young man who ended up killing himself. This was a tragedy and I remember feeling that gut-wrenching guilt and regret that really stays with you a long time. Afterwards, my consultation group quizzed me and declared that I had done what I could, following all the standard and customary professional suicide assessment procedures. But in my mind and in my heart, then and now, I know I could have done better.
You see back in 1991, professionals (and the public) lived by a big suicide-related myth. We generally viewed suicidal thoughts as DEVIANCE. And so, when clients talked of suicide, it was our job to take action to assess and intervene to eliminate the suicidal thoughts.
This way of thinking about suicide is unhelpful. It creates distance between the professional therapist and his or her client; it also takes power away from clients. And so it’s NOW TIME FOR US TO BUST THE BIG SUICIDE MYTH.
NO LONGER should we consider suicidal thoughts and impulses simply as SIGNS OF DEVIANCE. Instead, we should view suicidal thoughts and impulses as normal signs of human distress. THIS IS THE NEW – and the more accurate – REALITY
Let’s take a minute now to contrast traditional and contemporary or post-modern suicide assessment and intervention approaches. The old Narrative is sort of a checklist approach where we emphasize risk factors, diagnostic interviewing, and no-suicide contracts. The New Narrative is different; it involves looking for protective factors, client strengths, normalizing suicide ideation, and initiating a collaborative safety plan.
This is what I wish I’d understood back in 1991. And so I’d like to be more specific about what I would have done differently and what all mental health professionals should be doing differently.
I wish I had asked more about his protective factors. Protective factors are things like reasons for living and so I wish I’d been more courageous in sitting with him and exploring the reasons why he wanted to live. I wish I’d asked him, over and over, what would or what could help him want to live.
I wish I had asked him more directly about what would help him control his suicide impulses. I would have asked him who he wanted around to help him. I would have lingered on this and asked, who else, what if that person can’t be there, who else would be your next choice to turn to for help.
One of the big changes in the suicide intervention field is that we no longer ask clients to sign No-Suicide contracts. Instead, we work to collaboratively develop a safety plan. As a part of this different focus, I wish I had clearly and unequivocally said to him: “I WANT YOU TO LIVE.” This is different than arguing with clients about their right or need to commit suicide. We should never argue against suicide because that can activate client resistance and make the act even more likely. But the language, “I WANT YOU TO LIVE” is just a self-disclosure and is therefore unarguable. It clearly communicates the intent to help.
Overall, I should have been MORE BALANCED and asked about what my client was doing when his depressive symptoms were gone. I should have asked about what he hoped for today and tomorrow and into the future. I should have asked him more about what brought a little light into his darkness. We should have brainstormed how to bring the light in when he was feeling down.
One problem with the old No-Suicide contracts is that clients sometimes viewed them as designed more to protect the counselor than the client. Obviously this is backward and not the sort of message we want to give clients who are suicidal. And so no-suicide contracts are out . . . and collaborative safety plans are in. What this requires is for counselors to dig in deeper and explore together specifically what the client is willing to do if the suicidal impulses come.
And now, because this talk is all about balancing negative and positive and I want to give an example of two suicide interventions, I’m going to share a positive story about suicide. Maybe I shouldn’t have said that, because now you already know there’s a happy ending. Oh well. Having a happy ending story is a good thing when you’re doing a suicide presentation.
About 5pm one evening I was about to head home and got a call from an alcohol and drug prevention organization across the street from where I was working. A suicidal 16-year-old had suddenly walked into their agency and they had no professional therapists on staff. They asked me to come over and help. I went right over and sat down with the girl in their lobby. We talked a while and she said she had left the local psychiatric unit and was planning to kill herself by jumping off a bridge about a quarter mile away. I listened and then began a specific suicide intervention developed by Edwin Shneidman, well-known as the father of suicidology. I said something like, “So you want to kill yourself. That’s one option, but let’s look at some others.” She said she wasn’t interested in any other options, but I got out a sheet of paper and wrote down “Kill myself” in the left hand column and asked her for other options. She said, “I don’t have any other options.” I said, how about going back to the hospital?” She said, “No way.” I said, that’s okay, we’re just making a list. Got any ideas? She said nothing. I said, “How about some family therapy?” She said, “No way.” I said, “Okay. I’ll write it down anyway because we’re just making a list. You don’t have to do any of these things.” Over time, I came up with about eight ideas of what she might do instead of kill herself, but she hadn’t come up with any. But the purpose of the intervention I was using was to address what Shneidman calls mental constriction. Mental constriction occurs when suicidal individuals are feeling so stressed and miserable that all they can consider is continued misery or death by suicide. With this intervention, I was working on opening up her mental blinders so she could see and consider alternatives to suicide. And so despite the fact that she didn’t generate or endorse any of the alternatives, I handed her the sheet of paper and asked her to rank order her preferences. And somewhat to my surprise, she ranked “Kill myself” as number three. There were two other options she preferred over suicide. I went for that and asked how I could help her get family therapy, which was her first choice. She re-escalated and headed out the door and down the street toward the bridge. I followed and walked with her and talked on and on about how “I want you to live.” She eventually got to the corner where we would cross the street to get on the bridge and I said I was stopping there. She stopped too and I reached out and grabbed her hand. She pulled back and yelled at me for touching her. Then I tried another specific suicide intervention, called Neodissociation. I said, “I know somewhere inside there’s a part of you that wants to live a happy and healthy life. Please, I want that part of you to just reach out and take my hand and walk with me back to the office so we can get you the help you deserve. She stared at me, reached out, took my hand, and then walked back to the office where I called the police and they took her back to the hospital.
[Insert big sigh here].
About two months later, I got a card from her that read, “The only bridges in my life now are bridges to health and happiness.” Now that’s a pretty good ending, but there’s more.
About six months later I asked her therapist if he thought it would be okay for me to interview her about what she thought was most helpful to her in choosing life over suicide. He asked her and then she came to my office for a short video interview. I remember asking her what was most helpful and she said she had a great student nurse at the hospital who was “Fresh” and genuine and that had helped a lot. Then I asked her what had helped her come with me on that first night we’d met. She said, “I’m not sure.” Eager for affirmation, I asked if it was when I used the neodissociation technique and she responded, “No way. That was really stupid.” Then she spontaneously said that she thought it was the look on my face, when I stopped and said I would go no further. She said that—in that moment—I looked like I really cared.
And so that’s the suicide story I prefer to remember.
Speaking of remembering, let’s review the main points.
In summary, there are three main modifications to the traditional approach, which I sometimes call the NEW MANTRA.
• There’s NO MORE BIG MYTH and so we normalize suicidal thoughts and impulses to counter our client’s feelings of deviance; they already feel deviant enough, we don’t need to add to that.
• Collaborate with clients. . . and be sure to do so from a place of genuine caring. It’s okay to say: “I WANT YOU TO LIVE” while collaboratively developing a safety plan.
• Use strength-based questioning, focusing on hope instead of hopelessness; meaning instead of meaninglessness.
• And of course, as always, like all good professionals, consult and document.
I’d like to end with a comment on self-care. As you can see in the final photo, my two daughters are engaged in what appears to be rather bizarre human behavior. I like to think of this as the one daughter performing a helpful “Pit-Check” for the other. We all need that and we especially need that when we’re working with clients who are suicidal. We need to keep talking and asking, “How am I doing?” We need to check up and check in with our colleagues and take very good care of ourselves because although the work we’re doing is essential . . . it can also be terribly stressful to face alone.
This reminds me of what another client once said to me. He said: The mind is a terrible place to go . . . alone . . . which is why we should keep on talking—directly to each other and to our clients—about suicide and suicide prevention.
Thanks for listening.
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