Tag Archives: suicide prevention

New Journal Article – Conversations about suicide: Strategies for detecting and assessing suicide risk

Hey Blog Readers.

For those of you who might be interested, I just published a new article on suicide assessment and interventions in the Journal of Health Service Psychology. The article title is, “Conversations about suicide: Strategies for detecting and assessing suicide risk.” The article is designed to help practitioners who work or may find themselves working with suicidal clients.

Here’s a link to the article: https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

John Semi Prof

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Eight Core Conditions that Often Contribute to Suicide

Rainbow 2017Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.

Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.

Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.

Here are the eight dimensions.

Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)

Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.

Problem-Solving Impairment (Shneidman’s Mental Constriction)

Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).

Agitation or Arousal (Shneidman’s Perturbation)

Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).

Thwarted Belongingness and Perceived Burdensomeness

Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.

Hopelessness

Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.

Suicide Desensitization

Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.

Suicide Plan or Intent

In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.

Lethal Means

Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).

 

Straight Talk About Suicide Prevention

Gorge Chairs

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

Suicide Prevention Article in the Missoulian

Hi All.

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.

Here’s the link: http://missoulian.com/news/opinion/columnists/suicide-prevention-ignore-the-math/article_ce3c7f1e-ab86-587e-9505-310cc00b3355.html

Have a great rest of the week.

John SF

 

 

Suicide Assessment Powerpoints for MSU-Billings

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:

MSU Billings Suicide Talk

Three Strategies for Conducting State-of-the-Art Suicide Assessment Interviews

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: john.sf@mso.umt.edu or 406-721-6367.

 

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