Tomorrow morning, three counseling interns and I will hit the road for Ronan, where we’ll spend the day with the staff of CSKT Tribal Health. We are honored and humbled to engage in a conversation about how to make the usual medical model approach to suicide be more culturally sensitive and explicitly collaborative.
Here are the ppts for the day:
Tomorrow morning (Wednesday, October 2) I have the honor and privilege of being the keynote speaker for Maryland’s 36th Annual Suicide Prevention Conference. So far, everyone I’ve met associated with this conference is amazing. I suspect tomorrow will be filled with excellent presentations and fabulous people who are in the business of mental health and saving lives.
I hope I can do justice to my role in this very cool conference.
Here’s a link to tomorrow’s ppts:
Why Do We Need a Strengths-Based Approach to Suicide Assessment and Treatment?
Imagine this: You’re living in a world that seems like it would just as soon forget you exist. Maybe your skin color is different than the dominant people who hold power. Maybe you have a disability. Whatever the case, the message you hear from the culture is that you’re not important and not worthy. You feel oppressed, marginalized, unsupported, and as if much of society would just as soon have you become invisible or go away.
In response, you intermittently feel depressed and suicidal. Then, when you enter the office of a health or mental health professional, the professional asks you about depression and suicide. Even if the professional is well-intended, judgment leaks through. If you admit to feeling depressed and having suicidal thoughts, you’ll get a diagnosis that implies you’re to blame for having depressing and suicidal thoughts.
The medical model overfocuses on trying to determine: “Are you suicidal?” The medical model is also based on the assumption that the presence of suicidality indicates there’s something seriously wrong with you. But if we’re working with someone who has been or is currently being marginalized, a rational response from the patient might be:
“As it turns out, I’ve internalized systemic and intergenerational racism, sexism, ableism, and other dehumanizing messages from society. I’ve been devalued for so long and so often that now, I’ve internalized societal messages: I devalue myself and wonder if life is worth living. And now, you’re blaming me with a label that implies I’m the problem!”
No wonder most people who are feeling suicidal don’t bother telling their health professionals.
When I think of this preceding scenario, I want to add profanity into my response, so I can adequately convey that it’s completely unjust to BLAME patients for absorbing repeated negative messages about people who look like or sound like or act like them. WTH else do you think should happen?
This is why we need to integrate strengths-based principles into traditional suicide assessment and prevention models. Of course, we shouldn’t use strengths-based ideas in ways that are toxically positive. We ALWAYS need to start by coming alongside and feeling with our patients and clients. As it turns out, if we do a good job of coming alongside patients/clients who are in emotional pain, natural opportunities for focus on strengths and resources, including cultural, racial, sexual, and other identities that give the person meaning.
I’m reminded of an interview I did with an Alaskan Native person from the Yupik tribe. She talked at length about her depression, about feeling like a zombie, and past and current suicidal thoughts. Eventually, I inquired: “What’s happening when you’re not having thoughts about suicide?” She seemed surprised. Then she said, “I’d be singing or writing poetry.” I instantly had a sense that expressing herself held meaning for her. In particular, her singing Native songs and contemporary pop songs became important in our collaborative efforts to build her a safety plan.
This coming Wednesday morning I have the honor of presenting as the keynote speaker for the Maryland Department of Health 36th Annual Suicide Prevention Conference. During this keynote, I’ll share more ideas about why a strengths-based model is a good fit when working with diverse clients who are experiencing suicidal thoughts and impulses.
With all that said, here’s the title and abstract of my upcoming presentation.
Strengths-Based Assessment, Treatment, and Prevention with Diverse Populations
Traditional suicide assessment tends to be a top-down information-gathering process wherein healthcare or prevention professionals use questionnaires and clinical interviews to determine patient or client suicide risk. This approach may not be the best fit for people from populations with historical trauma, or for people who continue to experience oppression or marginalization. In this presentation, John Sommers-Flanagan will review principles of a strengths-based approach to suicide prevention, assessment, and treatment. He will also discuss how to be more sensitive, empowering, collaborative, and how to leverage cultural strengths when working with people who are potentially suicidal. You will learn at least three practical strengths-based strategies for initiating conversations about suicide, conducting culturally-sensitive assessments, and implementing suicide interventions—that you can immediately use in your prevention work.
Good Morning or Good Afternoon (wherever you may be),
In 28 minutes I’ll be online presenting for the Mental Health Academy Suicide Prevention Summit. A big thanks to Pedro and Greg for their organizing and broadcasting of this worldwide event. I’m honored to be a part of it.
It’s still not too late to register. The link is here: https://www.mentalhealthacademy.net/suicideprevention. It’s all free . . . or you can pay a whopping $10 and have access to all the recordings. TBH, I’m not sure if I’d pay $10 to hear me (jokes), but tomorrow morning features Craig Bryan, and I’ll be an early-riser to catch him live (and free). There are also some other FABULOUS presenters.
Here are my ppts . . . just so you all have them.
When I wrote this, I was listening to Dr. Jennifer Crumlish, a consultant for the CAMS-Care program. Dr. Crumlish provided a fantastic overview of the challenges associated with suicide prevention and interventions, along with introductory information pertaining to implementing the CAMS model. For more on CAMS-Care, see this link: https://cams-care.com/
Earlier in the day, Leah Finch—one of our excellent doc students in counseling—and I, did our presentation. Our participants were awesome. A bit later, I got to be on an “expert panel” along with several very cool people, facilitated by Dr. Jen Preble. We fielded an array of interesting questions from the audience. Very fun.
For those of you interested, here are the ppts Leah and I developed, here they are:
Yesterday I was at Camp Mak-A-Dream talking with young people about happiness. Today, I’ll be online with 400+ professionals doing a presentation titled: Strategies for Listening and Responding to People Who are Suicidal. Today’s presentation is offered through PacificSource, a health insurance provider in the NW United States.
Below, I’ve linked the ppts for today’s talk.
And here, I’ve linked a short handout that summarizes many, but not all, of the points in the presentation.
I’m presenting with one of our esteemed UM Doc students, Kanbi Knippling, M.A. You can see our title in the photo. Should be interesting and excellent content for anyone working with people who have disabilities. Kanbi is taking the lead, and I’m helping, which is fun for me.
Here are the ppts:
I’m on my way to Bozeman this morning. Below, I’m linking the ppts to my talk, as well as a one-page handout/summary.
Have a great Monday!
Early this morning, I had a chance to Zoom in and present a workshop for Saint Michael’s College in Vermont. This was probably a good thing, because they had more than their share of snow to deal with. I got to be in Vermont virtually from beautiful Missoula Montana, where we’ve had spring most of winter. I wish we could borrow a few feet of that Vermont snow to get us up to something close to normal.
But my point is to share my ppts from this morning, and not talk about the weather. I had a great two hours with the Saint Michael’s professionals . . . as they posed excellent and nuanced questions and made insightful comments. Here’s a link to the ppts:
Yesterday I had a chance to do a 3-hour online workshop with a very cool group of about 22 smart, skilled, and dedicated professionals. They engaged with the content and consequently, we had some great discussions. One of the discussions has kept percolating for me today. The topic: How do we handle situations where clients are clearly suicidal, but are reluctant or unwilling to develop and agree to a collaborative safety plan.
We talked about how, often, the knee-jerk impulse is to pursue hospitalization. While that’s a viable and reasonable option, the problem is that hospitalization and discharge is a notable risk factor for death by suicide. The other problem is that it’s pretty much impossible for us to know if the client’s resistance to a safety plan indicates increased risk, or just resistance to what s/he/they view as a coercive mandate.
There’s no perfect clinician response to this dilemma. Hospitalization helps some clients, and causes demoralization and regression in others. Not hospitalizing can feel too risky for practitioners.
We talked about a few guidelines in dealing with this conundrum. They include: (a) consulting with colleagues, (b) reflecting on the client’s engagement in other aspects of treatment (increased engagement in treatment is a protective factor), (c) evaluating client intent and client impulsivity, and (d) documenting your decision-making process (including citations indicating that psychiatric hospitalization may not be the best alternative). But again, there’s no perfect guideline.
Below is an excerpt from a CEU course I wrote about a year ago. For the whole CEU (actually there are two different CE courses), you can check out this link: https://www.continuingedcourses.net/active/courses/course114.php
Similar content is also in our brand new Clinical Interviewing textbook: https://www.wiley.com/en-cn/Clinical+Interviewing%2C+7th+Edition-p-9781119981992
Here’s the CEU excerpt:
Decision-Making Dilemmas
When discussing Kate’s situation and other scenarios that involve outpatient work with highly suicidal clients, the following question usually comes up, “What if your judgment is wrong and she either makes a suicide attempt, or she kills herself before your next session?” This is a great question and gets to the core of practitioner anxiety.
The answer is that, yes, she could kill herself, and if she does, I’ll feel terrible about my clinical judgment. Also, I might get sued. And, if I’m inclined toward suicidal thoughts myself, Kate killing herself might precipitate a suicidal crisis in me. Sometimes suicide tragedies happen, and sometimes we will feel like the tragedy was our fault and that we should have or could have prevented it. That said, most suicides are more or less unpredictable. Even if you think you’re correct in categorizing someone as high or low risk, chances are you’ll be wrong; many high-risk clients don’t die by suicide and some low-risk clients do (see Sommers-Flanagan, 2021, for a personal essay on coping with the death of a client to suicide; https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility).
More depressing is the reality that hospitalization – the main therapeutic option we turn to when clients are highly suicidal – isn’t very effective at treating suicidality and preventing suicide (Large & Kapur, 2018). Hospitalization sometimes causes clients to regress and destabilize, and suicide risk is often higher after hospitalization (Kessler et al., 2020). Because hospitalization isn’t a good fit for many clients who are suicidal and because we can’t predict suicide very well anyway, some cutting edge suicide researchers recommend intensive safety planning as a viable (and often preferred) alternative to hospitalization. In the case of Kate, as long as she’s willing to collaborate, and I’m able to contact her husband, and we can construct a plan that provides safety, then I’m on solid professional ground (or at least as solid as professional ground gets when working with highly suicidal clients).
Kessler, R. C., Bossarte, R. M., Luedtke, A., Zaslavsky, A. M., & Zubizarreta, J. R. (2020). Suicide prediction models: A critical review of recent research with recommendations for the way forward. Molecular Psychiatry, 25(1), 168-179. doi:http://dx.doi.org/10.1038/s41380-019-0531-0
Large, M. M., & Kapur, N. (2018). Psychiatric hospitalisation and the risk of suicide. The British Journal of Psychiatry, 212(5), 269-273.
Sommers-Flanagan, J. (2021, July/August). The myth of infallibility: A therapist comes to terms with a client suicide. Psychotherapy Networker. https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility
And here’s an excerpt from Clinical Interviewing.
Collaborate with Clients Who Are Suicidal
The idea that healthcare professionals must take an authoritarian role when evaluating and treating suicidal clients has proven problematic (Konrad & Jobes, 2011). Authoritarian clinicians can activate oppositional or resistant behaviors (Miller & Rollnick, 2013). If you try arguing clients out of suicidal thoughts and impulses, they may shut down and become less open.
For decades, no-suicide contracts were a standard practice for suicide prevention and intervention (Drye et al., 1973). These contracts consisted of signed statements such as: “I promise not to commit suicide between my medical appointments.” In a fascinating turn of events, during the 1990s, no-suicide contracts came under fire as (a) coercive and (b) as focusing more on practitioner liability than client well-being (Edwards & Sachmann, 2010; Rudd et al., 2006). Suicide experts no longer advocate using no-suicide contracts.
Instead, collaborative approaches to working with suicidal clients are strongly recommended. One such approach is the collaborative assessment and management of suicide (CAMS; Jobes, 2016). CAMS emphasizes suicide assessment and intervention as a humane encounter honoring clients as experts regarding their suicidal thoughts, feelings, and situation. Jobes and colleagues (2007) wrote:
CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts.” (p. 285)
John Sommers-Flanagan 