Tag Archives: suicide

Understanding Suicide – A Video/Podcast Interview with Paula Fontenelle

The word suicide, all by itself and regardless of context, can elicit anxiety, grief, anger, and other raw emotions. One of my goals as a mental health professional, is to advocate for open discussions of suicide. Why? Because I want to actively role model how facing, embracing, and discussing suicide directly can shrink the threatening nature of the word—and also shrink the anxiety, grief, and anger that people feel when they hear the word.

Just yesterday, Paula Fontenelle, author of “Understanding Suicide” (see Amazon: https://www.amazon.com/Understanding-Suicide-Living-loss-prevention/dp/1691504831), posted a podcast and video of her and I discussing suicide. As always, when I look at and listen to myself, I feel a bit shy about sharing this. The mirror (or video recording) is never as flattering as I wish it to be. However, I love that Paula is so dedicated to this topic and that she was willing to have me as a guest on the 1st anniversary and 40th episode of her show.

You can access a video of the show here: https://www.youtube.com/watch?v=RDmY8kgf6Zc

You can access the audio (podcast) of the show here: https://bit.ly/3muZ2eD

If you want to know more about Paula and her interests and expertise, you can link to her in all of the methods listed below:

WebsitePodcast | YouTube | LinkedIn | Facebook | Instagram

Thanks for reading, listening, and watching. I wish you all the best this weekend and beyond!

John

Suicide Assessment Should be Therapeutic Assessment

This morning (or afternoon, depending on your time zone), I’ll be participating on a panel discussion titled, “Treating and Preventing Suicide.” Although the event has reached maximum capacity, the link for more information is here: https://catalog.pesi.com/sq/pn_001386_essentialstreatingpreventingsuicide_panel_aca-139059?fbclid=IwAR2QYfDxVFjdnnDHV1JwKUYh54JqKzvhpneB98FF-yNrk5fcbFfPMdtyuWs

As a resource to complement the panel discussion, I’m posting some information on suicide assessment. Below is the opening from the suicide assessment chapter in our forthcoming book with the American Counseling Association. We emphasize that suicide assessment isn’t purely data collection. Instead, professionals need to simultaneously keep their eye on how to be therapeutic. Here’s the excerpt:

Suicide assessment integrates science and art. Assessment science helps practitioners determine what information is most important during a clinical interview and how to best obtain reliable and valid assessment data (Sommers-Flanagan et al., 2020; Wygant et al., 2020). The art of assessment includes how and when to ask questions, relational methods for offering empathy, and how clinicians can partner with clients to explore symptoms and strengths in ways that facilitate trust and stimulate honesty (Ganzini et al., 2013). Because suicide is a painful and provocative topic, advanced assessment skills are essential.

When clients or students experience suicidality, exposure to an assessment process can feel threatening. As a consequence, we believe counselors should embrace principles of therapeutic assessment (Fischer, 1970, 1985). Therapeutic assessment originated in the late 1960’s, when Constance Fischer began practicing and publishing about a radical new assessment approach. Unlike traditional objective and unilateral approaches to assessment, Fischer (1969, 1970) began viewing clients as “co-evaluators.” Stephen Finn has extended Fischer’s ideas; the approach is now called therapeutic assessment (Finn et al., 2012).

Therapeutic assessment principles are consistent with the professional counseling paradigm (Capuzzi & Stauffer, 2016); they include collaboration, compassion, openness, honesty, and a commitment to valuing clients as ultimate experts on their lived experiences. Although information gathering remains important, relationship connection during assessment interviews takes priority. Every assessment finding needs to be validated and understood within each client’s unique personal context. Collaboration is the cornerstone; assessments are done with clients, not on clients (Martin, 2020; Sommers-Flanagan & Sommers-Flanagan, 2017). As Flemons and Gralnik (2013) wrote, when conducting suicide assessments, “Our goal is not to remain objectively removed but, rather, to become empathically connected” (p. 6).

There are several “therapeutic” strategies for suicide assessment interviewing. Jobes’s (2016) book is a great resources, as is Freedenthal’s (2018). You can also check out our Clinical Interviewing suicide assessment chapter, or read this free blog post on using a mood scaling method: https://johnsommersflanagan.com/2018/05/25/suicide-assessment-mood-scaling-with-a-suicide-floor/

Obviously, there’s not enough time and space to go into great depth on suicide assessment in a little blog like this. And so, if you looking for depth, check out the video series I did with Victor Yalom and Psychotherapy.net. You can even watch a short demonstration video clip: https://www.psychotherapy.net/video/suicidal-clients-series

I wish you all the best as you face the challenge of engaging with and treating clients who are suicidal with the therapeutic respect they deserve.

Sweet Home Alabama — Suicide Workshop Handouts

See below for links to the handouts for the Alabama Counseling Association workshop on 8/21/20, titled, “Suicide Assessment and Treatment Planning: A Strength-Based Approach.” Although I wish I could be there in-person in Alabama, instead, we’ll get an exciting, live, and interactive Zoom workshop!

Powerpoint Slides are Here: Suicide Workshop Alabama

Extra Handouts are Here: Alabama Handouts 8 21 20

Talking with Clients who are Suicidal about Gun Safety

300px-Handgun_collection

The following is an excerpt from a section we’re developing in our strength-based suicide assessment and treatment book. Check it out and provide feedback if you like.

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Lethal Means Restriction (Safety)

Firearm availability or easy access to other lethal means is significantly linked to death by suicide (Bryan & Rudd, 2018). Access to lethal means is especially important because acute suicidal crises tend to be brief. If guns, razor blades, pills or other means are not immediately accessible, the crisis may pass without an attempt occurring. Summarizing pertinent research (Simon et al., 2001), Bryan and Rudd noted:

The final decision regarding the suicide attempt method typically occurs approximately 2 hours prior to the attempt, the final decision regarding the location of the attempt typically occurs approximately 30 minutes prior to the attempt, and the final decision to act typically occurs approximately 5 minutes prior to the attempt (p. 143).

Given that intense suicidal impulses usually pass quickly, limiting easy access to lethal means may be one of the most effective interventions available.

Bryan and colleagues (2011) published an article on how to engage clients who are suicidal in “means-restriction counseling.” As they noted, mental health professionals are expected to talk with clients about locking up and removing lethal means for suicide. However, little practical advice on how to do so is available (other than articles by Britton et al., 2016 & Bryan et al., 2011).

Early in her session with her counselor, 15-year-old Sophia (chapter 4), made it clear that she knew where her father kept the family’s guns. Although the counselor didn’t feel the need to immediately respond to her statement, as they worked on a collaborative safety plan later in the session, lethal means restriction came up for discussion:

Counselor: Sophia, we need to talk about a big issue that’s related to your safety. Is it okay with you if I just bring it up right now?

Sophia: Yeah.

Counselor: When people are suicidal, guns are the most dangerous thing to have in the house. Because my biggest goal is to keep you safe, we need to talk about how to lock up the guns or get them out of the house.

Sophia: My dad will completely freak about that.

Counselor: That’s okay. Lots of people have strong feelings about keeping guns in their homes. Don’t worry about talking with your dad, because I can do that. I want to keep you safe, but also respect your dad’s rights.

Sophia: Yeah. No way am I bringing that up.

Sophia’s reluctance to bring up gun safety with her father is natural. Her clear statement, “No way am I bringing that up,” means that bringing up gun safety is the counselor’s responsibility—as it should be.

Although phone conversations about gun safety with parents or family members may be helpful, we prefer a face-to-face contact when possible. In our experience, the best approach is to be direct, straightforward, and matter of fact. The core message is that because often suicidal impulses briefly escalate but then subside, all highly lethal methods should be locked away or removed.

Bryan and colleagues (2011) recommended presenting options for restricting firearms access. They presented options such as completely removing the means from the home by disposing of it or giving it to a supportive person. They noted you can also have clients lock up the means and give the key to a supportive person, or dismantle the firearm and give a critical piece to a supportive person (Bryan et al., 2011, pp. 341-342).

Discussing firearms during counseling sessions can result in instant escalation and polarization. Preparation helps. We recommend the following:

  • Be prepared talk about firearm safety. Talking directly about firearm safety is one of the most effective methods you have for reducing risk.
  • Keep a laser-focus on safety; avoid using the word “restriction.” Your discussion isn’t about restrictions on firearms or gun rights. Your discussion is about safety.
  • If it feels helpful, say, “I support your second amendment rights.” Conversations about firearms in the context of suicide prevention don’t need to be political.
  • As needed, state unequivocally, “I want to respect your right to own your guns . . . AND I want you (or your daughter) to be safe and to live a long and fulfilling life.”
  • Brainstorm different methods for enhancing safety. Recognize that there are two general approaches to gun safety: (a) removing firearms from the premises and (b) creating obstacles to impulsive use of firearms during a suicidal crisis (e.g., trigger locks, gun safes). Although removing guns is the safest alternative, creating obstacles is a reasonable alternative. You may want to conduct your brainstorming with the parent, client, essential support person, or all of the above.
  • Remember that because there’s no single perfect safety solution and because nearly everyone is more agreeable if they participate in a decision-making process, less directive procedures like Socratic questioning and motivational interviewing may be preferable.

If you’d rather not be boldly direct about gun safety, consider using Socratic questions to help clients come to their own conclusions. Bryan and Rudd (2018) recommend questions such as, “What do you think about someone having access to guns when they’re really upset and are suicidal?” “What might be some benefits of temporarily limiting your access to firearms?” “If complete removal of the guns is not possible, what are some other options for practicing good gun safety while you’re going through this treatment?” “What do you think about putting together a plan for this?” (p. 148).

Motivational interviewing (MI) is another less-directive method for discussing firearms safety. Keeping in mind the core principle of MI—that clients should be the ones making the case for change—clinicians can use open-ended questions, reflections, affirmation, and other technical strategies to increase firearms safety (Miller & Rollnick, 2013). The following short exchange is excerpted from an extended case example where a veteran has refused to remove his firearms, and so clinician is using MI to elicit talk around adding obstacles to enhance safety (see Britton et al., 2016, pp. 56-58, for the full case example).

**To be continued**

Suicide Education Resources . . . and Why is it so Easy to Experience Imposter Syndrome?

What’s Wrong with Suicide Assessment?

Rainbow 2020

I’ve been contemplating whether anyone likes to go for medical examinations. I’m thinking of colonoscopies, dental exams, mammograms, stress tests, blood draws, and other more or less routine examinations of physical functioning. I’m guessing most people don’t like these procedures much, even though medical examinations  provide important information and can contribute to our good health and well-being.

Why are medical and physical assessments so darn unpleasant? One part of the unpleasantness is probably the intrusiveness. Assessments are all about gathering information; medical assessments involve gathering information about things that trigger vulnerability. Sometimes we have to be naked while we let strangers look at us and poke and prod our bodies. Even worse, medical examinations generally focus on our flaws, our weaknesses, and potential illness or disease. Whether we’re stepping on the scale in front of the medical technician or being asked, “How much alcohol do you drink?” insecurities and defensiveness can get activated. Two weeks ago when I got weighed at the doctor’s office, I wanted to complain, “Hey. That’s not right. Your scales are off. At home I weigh at least 6 pounds less than that!” What stopped me? The realization that complaining about my weight might look and sound even worse than just accepting the number. . . and so I kept quiet about my opinion. Partly–as one of my former grad students would say–we’re all about impression management.

If physical examinations trigger insecurity and vulnerability, just imagine what gets triggered in the mental and emotional domains. While at the medical office I got asked items from the PHQ-9 and GAD-7. I said “No” to every symptom, explaining, “Hey. I know all about these assessments and have written articles about them.” My med tech person wasn’t especially interested. I suspect, given her devotional attention to the computer screen, that she might not have been super-interested even if I had complained of depression or anxiety symptoms. But that’s speculation. She might have turned to me and tuned in like an empathic laser.

Nowadays, everybody is supposed to be on the alert and, if needed, ask about suicide. This idea, although theoretically great, doesn’t work all that well in reality. During a recent integrated behavioral health (IBH) training I learned of an IBH program that’s now devoting a whole three minutes to suicide assessment. Oh my. No wonder, based on a meta-analysis of 70 studies, about 60% of people who died by suicide, denied suicide ideation when asked by a general practitioner or psychiatrist (McHugh et al., 2019).

In an early version of the assessment chapter of our upcoming book on suicide assessment and treatment, I jumped headlong into the problems with suicide assessment. I figured, if answering questions about weight or alcohol consumption activate vulnerability and defensiveness, getting asked, “Have you thought about suicide?” likely stokes even greater insecurity and potentially stimulates even more evasiveness.

My early draft section on what’s wrong with suicide assessment, got substantially re-worked, maybe because some people thought I should be nicer, and maybe because I agreed with those people. However, right here on my very own blog I don’t necessarily have to be nicer. You all can tell me if I’m being too mean.

But before we get lost in my not-quite-ready-for-prime-time text below, here are my general conclusions.

1. Although questionnaires are fine for gathering information, if people are suicidal we need to rely on clinical interviews, rather than questionnaires.

2. We should ask about strengths, and not just problems (like the PHQ).

3. We should use normalizing questions (as I’ve written about before). We also need to train people how to use normalizing questions.

4. We should ask with kindness, compassion, and empathy . . . and be prepared to spend more than three minutes on the topic. We also need to train people on how to spend more than three minutes on the topic.

And finally . . . here’s the excerpt.

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Currently, in the United States, more professionals are conducting more suicide screenings and suicide assessments than ever before in the history of time. This fact begs the question: If we’re conducting more suicide screenings than ever, why are suicide rates continuing to rise? Could it be possible that suicide screenings increase suicidality?

Traditional responses to this question include:

  • We don’t know why suicide rates continue to rise despite prevention efforts
  • Asking about suicide doesn’t cause or increase suicidality.

For many years suicide researchers and practitioners have emphasized that asking about suicide doesn’t increase suicidality. Everyone in the suicidology field teaches that clinicians, paraprofessionals, and concerned non-professionals should ask directly about suicide ideation. We agree with this stance. The unanimous message is:

Clinicians should ask directly about suicide. Asking directly doesn’t increase risk or put the idea into the client’s head. Most clients either accept questions about suicide as a standard mental health practice, or feel relieved to be asked about suicide.

Despite our agreement with the philosophy of asking directly, all too often, when we’ve witnessed the question being asked, we’ve seen it asked badly. In one case, as a part of a mental status examination, we saw a social worker ask an elderly man, “Have you had thoughts about suicide?” The man responded, “I don’t know.” The social worker rephrased the question, “Do you think about death and dying?” Again, the man said, “I don’t know.” The social worker moved on. There was no follow up.

In another case, we listened as a nurse used a suicide assessment protocol during an initial interview. She asked a question from item 9 of the Patient Health Questionnaire-9 (PHQ-9): “Have you had thoughts that you would be better off dead, or of hurting yourself?” The patient said, “Yes.” Then, much to our surprise, the nurse simply asked another question. There was no empathy. There was no compassion. The nurse looked back at her clipboard, made a note, and continued asking questions from a script. Apparently the script didn’t include a box for checking off empathy or compassion.

Over the past decade we’ve repeatedly been asked to consult with schools on their suicide assessment and referral process. All too often we’ve heard from exasperated school counselors and school psychologists about how much they hate trying to interpersonally engage potentially suicidal students using a risk factor checklist or questionnaire items. School professionals complain about rigid procedures that result in referrals to the local hospital emergency department and end in ruptured therapeutic relationships.

Beyond these less-than-optimal scenarios, there’s empirical evidence indicating that suicide assessment procedures don’t always have neutral or positive effects. Harris and Goh (2017) conducted a randomized control trial evaluating the emotional effects of a suicide assessment protocol on Singapore residents. Although they reported no evidence for iatrogenic effects, 24% of participants experienced increased negative affect following administration of the Suicide Affect-Behavior-Cognition scale (Harris et al., 2015). Using a similar protocol, a Dutch research team reported similar results (de Beurs, Ghoncheh, Geraedts, & Kerkhof, 2016). After responding to 21 items from the Beck Scale for Suicide Ideation (BSSI, **), participants generally reported increased negative affect. In particular, about 15% of the BSSI group had substantially negative affective responses to the BSSI items.

We have no doubt that the social worker, the nurse, and the school districts featured in the preceding examples of poor suicide assessment were well-intended. For many reasons—including anxiety, lack of professional training, client hostility, fears of liability, or countertransference reactions—professionals often engage poorly with suicidal clients. We’re also certain that most of the time, clients view questions about suicide as necessary, and sometimes consider queries about suicide a welcome relief. However, we also believe, as in the two research examples, that repeated questioning about depression, suicide, anxiety, insomnia, and other aversive symptoms—without a skilled clinician to collaboratively explore depressive symptoms and reorient clients toward strengths and positive experiences—can activate negative affect. These reasons—and more—have convinced us that mental health and school professionals can do better than simply administering the PHQ-9, the BSSI items, and following a checklist when evaluating for suicide. Instead, professionals should balance their questioning, follow-up sensitively to clients’ responses, and validate that suicidal thoughts are a natural reaction to painful emotions and disturbing situations. All this points to the need to view suicide assessment differently; instead of adopting an authoritative assessment role, we encourage you to apply the principles of therapeutic assessment when conducting suicide assessment interviews.

Despite our critique of how suicide assessment is practiced, we strongly recommend that you follow the usual guidance, and ask directly about suicide ideation. We just want to add, you should do it right. The rest of this chapter is all about how to weave in therapeutic assessment principles so you can do suicide assessment right.

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As always, let me know what you think. I promise to be nice.

 

 

Individualizing Suicide Risk Factors in the Context of a Clinical Interview

Spring 2020

In response to my recent post on “The Myth of Suicide Risk and Protective Factors” Mark, a clinical supervisor from Edmonton, wrote me and asked about how to make individualizing suicide risk factors with clients more concrete/practical and less abstract. I thought, “What a great question” and will try to answer it here.

Let’s start with two foundational prerequisites. First, clinical providers need to be able to ask about suicide in ways that don’t pathologize the patient/client. Specifically, if clients fear that disclosing suicide ideation will result in them being judged as “crazy” or in involuntary hospitalization, then they’re more likely to keep their suicidal thoughts to themselves. This fear dynamic is one reason why we emphasize using a normalizing frame when asking about suicide.

Second, both before and after suicide ideation disclosures, providers need to explicitly emphasize collaboration. Essentially, the message is: “All we’re doing is working together to better understand and address the distress or pain that underlies your suicidal thoughts.” In other words, the focus isn’t on getting rid of suicidal thoughts; the focus is on reduction of psychological pain or distress.

With these two foundational principles in place, then the provider can collaboratively explore the primary and secondary sources of the client’s psychological pain. In our seven-dimensional model, we recommend exploring emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual sources of pain. Collaborative exploration is fundamental to individualizing risk factors. The general statistics showing that previous attempts, social isolation, physical illness, being male, and other factors predict suicide are mostly useless at that point. Instead, your job as a mental health provider is to pursue the distress. By pursuing the distress, you discover individualized risk factors. The following excerpt from our upcoming book illustrates how asking about “What’s bad” and “What feels worst?” results in individualized risk factors.

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     The opening exchange with Sophia is important because it shows how clinicians—even when operating from a strength-based foundation—address emotional distress. In the beginning the counselor drills down into the negative (e.g., “What’s making you feel bad?”), even though the plan is to develop client strengths and resilience. By drilling down into the client’s distress and emotional pain, and then later identifying what helps the client cope, the counselor is individualizing risk and protective factor assessment, rather than using a ubiquitous checklist.

Counselor: Sophia, thanks for meeting. I know you’re not super-excited to be here. I also know your parents said you’ve been talking about suicide off and on for a while, so they wanted me to talk with you. But 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 if you’re 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 you’re feeling?

The counselor began with an acknowledgement and quick summary of what he knew. This is a basic strategy for working with teens (Sommers-Flanagan & Sommers-Flanagan, 2007), but also can be true when working with adults. If counselors withhold what they know about clients, rapport and relationship development suffers.

The opening phrase “I don’t know. . .” acknowledges the limits of the counselor’s knowledge and offers an invitation for collaboration. Effective clinicians initially and intermittently offer invitations for collaboration to build the working alliance (Parrow, Sommers-Flanagan, Sky Cova, & Lungu, 2019). The underlying message is, “I want to help, but I can’t be helpful all on my own. I need your input so we can work together to address the distress you’re feeling.”

The opening question for Sophia is negative (i.e., What’s making you feel bad or sad or miserable or whatever it is you’re feeling?). This opening shows empathy for the emotional distress that triggers her suicidality and clarifies the link between her emotional distress and the triggering situations. By tuning into negative emotions, the counselor hones in on the presumptive primary treatment goal for all clients who are suicidal—to reduce the perceived intolerable or excruciating emotional distress (Shneidman, 1993).

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Collaborative exploration is the method through which risk and protective factors are individualized. If Sophia had a previous attempt, the reason to explore the previous attempt would be to discover what created the emotional distress that provoked the attempt, and how counseling or psychotherapy might address that particular factor. For example, if bullying and lack of social connection triggered Sophia’s attempt, then we would view bullying and social disconnection as Sophia’s particular individualized risk factors. We would then build treatments—in collaboration with Sophia and her family—that directly address the unique factors contributing to her pain, and provide her with palpable therapeutic support.

I hope this post has clarified how to individualize suicide risk factors and use them in treatment. Thanks for the question Mark!

A Strength-Based Suicide Assessment and Treatment Model

Bikes Snow 3

Over the past couple years, with feedback from workshop participants, supervisees, clients, and people with lived experiences around suicide, we’ve continued to refine our strength-based suicide assessment and treatment model. Below is a short excerpt from chapter 1 of our upcoming book. This excerpt gives you a glimpse at the strength-based model.

Seven Dimensions of Being Human: Where Does It Hurt and How Can I Help?

We began this chapter describing the case of Alina. Mostly likely, what you remember about Alina is that she displayed several frightening suicide risk factors and openly shared her suicidal thoughts. However, Alina is not just a suicidal person—she’s a unique individual who also exhibited a delightful array of idiosyncratic quirks, problems, and strengths. Even her reasons for considering suicide are unique to her.

When working with suicidal clients or students, it’s easy to over-focus on suicidality. Suicide is such a huge issue that it overshadows nearly everything else and consumes your attention. Nevertheless, all clients—suicidal or not—are richly complex and have a fascinating mix of strengths and weaknesses that deserve attention. To help keep practitioners focused on the whole person—and not just on weaknesses or pathology—we’ve developed a seven-dimension model for understanding suicidal clients.

Suicide Treatment Models

In the book, Brief cognitive-behavioral therapy for suicide prevention, Bryan and Rudd (2018) describe three distinct models for working with suicidal clients. The risk factor model emphasizes correlates and predictors of suicidal ideation and behavior. Practitioners following the risk factor model aim their treatments toward reducing known risk factors and increasing protective factors. Unfortunately, a dizzying array of risk factors exist, some are relatively unchangeable, and in a large, 50-year, meta-analytic study, the authors concluded that risk factors, protective factors, and warning signs are largely inaccurate and not useful (Franklin et al., 2017). Consequently, treatments based on the risk factor model are not in favor.

The psychiatric model focuses on treating psychiatric illnesses to reduce or prevent suicidality. The presumption is that clients experiencing suicidality should be treated for the symptoms linked to their diagnosis. Clients with depression should be treated for depression; clients diagnosed with post-traumatic stress disorder should be treated for trauma; and so on. Bryan and Rudd (2018) note that “accumulating evidence has failed to support the effectiveness of this conceptual framework” (p. 4).

The third model is the functional model. Bryan and Rudd (2018) wrote: “According to this model, suicidal thoughts and behaviors are conceptualized as the outcome of underlying psychopathological processes that specifically precipitate and maintain suicidal thoughts and behaviors over time” (p. 4). The functional model targets suicidal thoughts and behaviors within the context of the individual’s history and present circumstances. Bryan and Rudd (2018) emphasize that the superiority of the functional model is “well established” (p. 5-6).

Our approach differs from the functional model in several ways. Due to our wellness and strength-based orientation, we studiously avoid presuming that suicidality is a “psychopathological process.” Consistent with social constructionist philosophy, we believe that locating psychopathological processes within clients, risks exacerbation and perpetuation of the psychopathology as an internalized phenomenon (Hansen, 2015; Lyddon, 1995). In addition to our wellness, strength-based, social constructionist foundation, we rely on an integration of robust suicide theory (we rely on works from Shneidman, Joiner, Klonsky & May, Linehan, and O’Connor). We also embrace parts of the functional model, especially the emphasis on individualized contextual factors. Overall, our goal is to provide counseling practitioners with a practical and strength-based model for working effectively with suicidal clients and students.

The Seven Dimensions

Thinking about clients using the seven life dimensions can organize and guide your assessment and treatment planning. Many authorities in many disciplines have articulated life dimensions. Some argue for three, others for five, seven, or even nine dimensions. We settled on seven that we believe reflect common sense, science, philosophy, and convenience. Each dimension is multifaceted, overlapping, dynamic, and interactive. Each dimension includes at least three underlying factors that have theoretical and empirical support as drivers of suicide ideation or behavior. The dimensions and their underlying factors are in Table 1.1.

Insert Table 1.1 About Here

Table 1.1: Brief Descriptions of the Seven Dimensions

  • The Emotional Dimension consists of all human emotions ranging from sadness to joy. Empirically supported suicide-related problems in the emotional dimension include:
    • Excruciating emotional distress
    • Specific disturbing emotions (i.e., guilt, shame, anger, or sadness)
    • Emotional dysregulation
  • The Cognitive Dimension consists of all forms of human thought. Empirically supported suicide-related problems in the cognitive dimension include:
    • Hopelessness
    • Problem-solving impairments
    • Maladaptive thoughts
    • Negative core beliefs and self-hatred
  • The Interpersonal Dimension consists of all human relationships. Empirically supported suicide-related problems in the interpersonal dimension include:
    • Social disconnection, alienation, and perceived burdensomeness
    • Interpersonal loss and grief
    • Social skill deficits
    • Repeating dysfunctional relationship patterns
  • The Physical Dimension consists of all human biogenetics and physiology. Empirically supported suicide-related problems in the physical dimension include:
    • Biogenetic predispositions and illness
    • Sedentary lifestyle (lack of movement)
    • Agitation, arousal, anxiety
    • Trauma, nightmares, insomnia
  • The Spiritual-Cultural Dimension consists of all religious, spiritual, or cultural values that provide meaning and purpose in life. Empirically supported suicide-related problems in the spiritual-cultural dimension include:
    • Religious or spiritual disconnection
    • Cultural disconnection or dislocation
    • Meaninglessness
  • The Behavioral Dimension consists of human action and activity. Empirically supported suicide-related problems in the behavioral dimension include:
    • Using substances or cutting for desensitization
    • Suicide planning, intent, and preparation
    • Impulsivity
  • The Contextual Dimension consists of all factors outside of the individual that influence human behavior. Empirically supported suicide-related problems in the contextual dimension include:
    • No connection to place or nature
    • Chronic exposure to unhealthy environmental conditions
    • Socioeconomic oppression or resource scarcity (e.g., Poverty)

End of Table 1.1

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This past week Rita and I submitted the final draft manuscript to the publisher. The next step is a peer review process. While the manuscript is out for review, there’s still time to make changes and so, as usual, please email me with feedback or post your thoughts here.

Thanks for reading!

John S-F

The Myth of Suicide Risk and Protective Factors

 

HummingbirdMyths are fascinating, resilient ideas that openly defy reality.

Some people say, “All myths are based in truth.” Well, maybe so, but tracking down the myth’s truthful origins reminds me of my friends back in high school who used to take their dates snipe hunting. Maybe the idea that all myths are based in truth is a myth too?

Suicide is a troubling problem (this is an obvious understatement). To deal with this troubling problem, one of the tools that most well-intended prevention programs advocate is to watch for suicide risk factors and warning signs, and when you see them, intervene. This would be great guidance if only useful or accurate suicide risk factors and warning signs existed. Sadly, like the snipe, you can look all night for useful or accurate risk factors and still come up empty.

I’m writing about mythical risk factors and warning signs today because I just covered this content in our suicide assessment and treatment manuscript. In the following excerpt, we’re writing about suicide competencies for mental health professionals:

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Cramer and colleagues (2013) noted, “One of the clinician’s primary objectives in conducting a suicide risk assessment is to elicit risk and protective factors from the client” (p. 6). As we’ll discuss in greater detail later, this competency standard is problematic for at least three reasons. First, in an extensive meta-analysis covering 50-years of research, the authors concluded: “All [suicide thoughts and behavior] risk (and protective factors) are weak and inaccurate. This general pattern has not changed over the past 50 years” (Franklin, et al., 2017, p. 217).

Second, the number of potential risk and protective factors that counselors should be aware of is overwhelming. Granello (2010a) reported 75+ factors, we have a list of 25 (Sommers-Flanagan & Sommers-Flanagan, 2017), and even Cramer and colleagues lamented, “It would be impossible for clinicians to be familiar with every risk factor” (p. 6). Jobes (2016) referred to suicidology as “a field that has been remarkably obsessed with delineating countless suicide ‘risk factors’ (that do little for clinically understanding acute risk)” (p. 17).

Third, prominent suicide researchers have concluded that using risk and protective factors to categorize client risk is ill-advised (McHugh, Corderoy, Ryan, Hickie, & Large, 2019; Nielssen, Wallace, & Large, 2017). For example, even the most common suicide symptom and predictor (i.e., suicide ideation), is a poor predictor of suicide in clinical settings; this is because suicide ideation occurs at a very high frequency, but death by suicide occurs at a very low frequency. In one study, 80% of patients who died by suicide denied having suicidal thoughts, when asked directly by a general medical practitioner (McHugh et al., 2019). Even the oft-cited risk factor of previous suicide attempt has little bearing whether or not individuals die by suicide.

When AAS (2010) and Cramer and his colleagues (2013) described the risk and protective factor competency, eliciting risk and protective factors from clients was standard professional practice. However, in recent years, researchers have begun recommending that practitioners avoid using risk and protective factors to categorize client risk as low, medium, or high—principally because these categorizations are usually incorrect (Large, & Ryan, 2014). In a review of 17 studies examining 64 unique suicide prediction models, the authors reported that “These models would result in high false-positive rates and considerable false-negative rates if implemented in isolation” (Belsher et al., 2019, p. 642).

To summarize, this suicide competency boils down to four parts:

  1. Competent practitioners should still be aware of evidence-based suicide risk and protective factors.
  2. Competent practitioners are aware that evidence-based suicide risk and protective factors may not confer useful information during a clinical interview.
  3. Instead of over-relying on suicide risk and protective factor checklists, competent practitioners identify and explore client distress and then track client distress back to individualized factors that increase risk and enhance protection.
  4. Competent practitioners use skills to collaboratively develop safety plans that address each client’s unique risk and protective factors.

Although risk and protective factors don’t provide an equation that tell clinicians what to do, knowing and addressing each unique individual’s particular risks and strengths remains an important competency standard.

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As always, even though getting feedback on this blog is yet another mythical phenomenon,  please send me your thoughts and feedback!

 

 

 

Our Upcoming ACA Book on Suicide Assessment and Treatment Planning: Sneak Peek #2

River Rising 2020

Hey,

I hope you’re all okay and social distancing and mask wearing and hand-washing and staying healthy and well.

Today I’m working on Chapter 6 – The Cognitive Dimension in Suicide Assessment and Treatment Planning (or something like that).

As always, please share your feedback. Or, if you have no feedback and like what you read, just share the post, because, as we all know, acts of kindness grow happiness.

Here’s an excerpt on working with hopelessness.

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Working with Hopelessness as it Emerges During Sessions

Clinicians can address hopelessness in two ways. First, when hopelessness emerges in the here-and-now, clinicians need to be ready to respond empathically and effectively. Client hopelessness manifests in different ways. Sometimes hopelessness statements have depressing content (e.g., “I’ve never been happy and I’ll never be happy”); other times hopelessness statements include irritability (e.g., “Counseling has never worked for me. I hate this charade. It won’t help.”). Either way, in-session hopelessness statements can be provocative and can trigger unhelpful responses from counselors. Preparing yourself to respond therapeutically is important.

Second, hopelessness among clients who are depressed and suicidal manifests as an ongoing, long-term cognitive style. As with most cognitive styles, hopelessness is linked to cognitive distortions wherein clients have difficulty (a) recalling past successes, (b) noticing signs of hope in the immediate moment, or (c) believing that their emotional state or life situation could ever improve. We address in-session hopelessness next and hopelessness as a longer-term cognitive distortion in the subsequent section.

Expressing Empathy

Imagine you’re working with a new client. You want to be encouraging, and so you make a statement about the potential for counseling to be helpful. Consider the following exchange:

Counselor: After getting to know you a bit, and hearing what’s been happening in your life, I want to share with you that I think counseling can help.

Client: I know you mean well, but this is a waste of time. My life sucks and I want to end it. Popping in to chat with you once a week won’t change that.

When clients make hopelessness statements, you may feel tempted to counter with a rational rebuttal. After all, if client hopelessness represents a pervasive depression-related cognitive distortion or impairment, then it makes sense to offer a contrasting rational and accurate way of thinking. Although instant rational rebuttals worked for Albert Ellis, for most counselors, immediately disputing your clients’ global, internal, and hopeless cognitions will create resistance. Instead, you should return to an empathic response.

Counselor: I hear you saying that, right now, you don’t think counseling can help. You feel completely hopeless, like your life sucks and is never going to change and you just want it to end.

Staying empathic—even though you know that later you’ll be targeting your client’s hopeless distorted thinking—requires accurately reflecting your clients’ hopelessness. You may even use a tiny bit of motivational interviewing amplification (i.e., using the phrase, “never going to change” could function as an amplification). What’s important to remember about this strategy is that mirroring your clients’ hopelessness will likely stand in stark contrast to what your clients have been experiencing in their lives. In most situations, if your clients have spoken about their depression and suicidality with friends or family, they will have heard responses that include reassurance or emotional minimization (e.g., “I’m sure things will get better” or “You’re a wonderful person, you shouldn’t think about suicide” or “Let’s talk about all the blessings you have in your life”).

Remaining steadily empathic with clients as they express hopelessness is an intentionally different and courageous way to do counseling. Staying empathic means that you’re sticking with your clients in their despair. You’re not running from it; you’re not minimizing it; you’re not brushing it aside as insignificant. Instead, you’re resonating with your clients’ terribly depressive and suicidal cognitive and emotional experiences.

If you choose the courageous and empathic approach to counseling, you need to do so with the conscious intention of coming alongside your clients in their misery. Following the empathic path can take you deep into depressive ways of thinking and emoting. This can affect you personally; you may begin adopting your clients’ impaired depressive thinking and then feel depressed yourself. Part of being conscious and intentional means you’re choosing to temporarily step alongside and into your clients’ depressive mindset. You need to be clear with yourself: “I’m stepping into the pit of depression with my client, but even as I’m doing this, my intention is to initiate Socratic questioning or cognitive restructuring or collaborative problem-solving when the time is right.”

The next question is: “How long do you need to stay alongside your client in the depressive mindset?” The answer varies. Sometimes, just as soon as you step alongside your clients’ hopelessness, they will rally and say something like, “It’s not like I’m completely hopeless” or “Sometimes I feel a little hope here or there.” When your client makes a small, positive statement, your next job is to gently nurture the statement with a reflection (e.g., “I hear you saying that once in a while, a bit of hope comes into your mind”), and then explore (and possibly grow) the positive statement with a solution-focused question designed to facilitate elaboration of the exceptional thought (e.g., “What was different about a time when you were feeling hopeful?”). Then, for as long as you can manage, you should follow Murphy’s (2015) solution-focused model for working with client exceptions. This includes:

  1. Elicit exceptions. (You can do this be asking questions like “What was different. . .” and by using the motivational interviewing techniques of coming alongside or amplified reflection.)
  2. Elaborate exceptions. (You do this with questions like “What’s usually happening when you feel a bit of hope peek through the dark clouds?”)
  3. Expand exceptions. (You move exceptions to new contexts and try to increase frequency, “What might help you feel hope just a tiny bit more?”)
  4. Evaluate exceptions. (You do this by collaboratively monitoring the utility or positivity of the exception, “If you were able to create reminders for being hopeful to use throughout the day, would you find that a plus or minus in your life?”)
  5. Empowering exceptions. (You do this by giving clients credit for their exceptions and asking them what they did to make the exceptions happen, “How did you manage to get yourself to think a few positive thoughts when you were in that conflict with your supervisor?”).

In other cases, you’ll need to stick with your clients’ misery and hopelessness longer. However, because this is a strength-based model and because the evidence suggests that clients who are suicidal sometimes need their counselor to explicitly lead them toward positive solutions, you will need to watch for opportunities to turn or nudge or push your clients away from abject hopelessness.