Tomorrow I’ll be presenting all day on Strengths-Based Suicide Assessment and Treatment at Water’s Edge Counseling Services in Rogers, Arkansas. Water’s Edge Counseling Services employs dozens of therapists at four locations. They continue to grow to meet the mental health needs of Arkansas residents. You can find information about their services here: https://www.watersedgecounselingnwa.com/
In anticipation of tomorrow, I looked up some stats on suicide in Arkansas and the U.S.
In the U.S. – the average rate of death by suicide (from 2022) is 14.5 per 100,000
New Jersey had the lowest 2022 rates at 7.6.
Wyoming had the highest at 31.8.
Arkansas was at 19.5.
Montana was at 27.5.
Today has been a hard day in Montana, as I’ve heard about two deaths by suicide by individuals in the social world of friends and family. Suicides are tragic and difficult to understand. When suicide happens, it’s important to remember many things, but a couple key points come to mind today.
It’s estimated that each suicide affects about 150 people. If you’re feeling guilty and like you should have or perhaps could have done something to save a life, you’re likely not alone.
Although you’ll often see messages in suicide prevention presentations or on the internet that suicide is 100% preventable, that’s not really true. In fact, we do more prevention now than ever before in the history of time and the U.S. rates have steadily risen over the past 25 years, in the face of all our prevention efforts.
My big points are that suicide is very difficult to predict and prevent and yet it’s very easy and common for people to feel guilty when someone they know dies of suicide . . . even though the people left behind are not at fault.
However your day has gone today, I wish you as much peace and comfort as possible. If you’re feeling suicidal or especially guilty, please reach out to someone who loves you. They will be happy to talk. Or, if you feel the need, you can call the national suicide crisis hotline: 988. Or, if you’re a texter, there’s a text hotline. Just text HOME to 741741 to connect with a volunteer Crisis Counselor.
All my best to you . . . and here are the ppts for tomorrow’s presentation:
In the piece I review some information and make one point that I’d like to share more broadly. Below are several opening paragraphs from the Op-Ed piece.
*Beginning of Excerpt*
Beyond Suicide Prevention: The Montana Happiness Challenge
John Sommers-Flanagan, Ph.D.
All September, organizations and individuals celebrated suicide prevention month, sharing information about suicide and promoting strategies for preventing suicide deaths. Although the information was life-affirming, underneath the messaging lies an unpleasant truth: Broadly speaking, suicide prevention has been failing for over two decades.
In August, the Centers for Disease Control (CDC) released provisional United States suicide data for 2022. The news was bad. An estimated 49,449 Americans died by suicide in 2022—the highest number ever recorded in U.S. history.
The bad news goes far beyond last year. Suicide rates have risen every year for over 20 years, with only two puzzling exceptions. In 2020 and 2021—during the onset of COVID-19, lockdowns, and other national stressors—suicide rates declined; they declined despite the fact that by every other measure Americans were suffering from unprecedented stress, depression, anxiety, and suicidal thinking. Suicide researchers have long noted this odd pattern: higher stress, depression, anxiety, and suicidal thinking do not inevitably translate to more suicides.
If all this seems confusing—20 years of vigorous suicide prevention, and suicide rates steadily rise, while during 2 years of intensive COVID-related individual and public distress, suicide rates go down—it’s only because it is.
In his book, Rethinking suicide, Craig Bryan, a renowned suicide researcher, called suicide “a wicked problem,” noting, “Wicked problems cannot be definitively solved or completely eliminated . . .” In fact, as Bryan and others have described, efforts to eliminate wicked problems sometimes make them worse. The preceding facts don’t indicate suicide prevention doesn’t work . . . and they don’t mean COVID pandemics solve the suicide problem. What they do mean—at minimum—is that suicide prevention doesn’t work for everyone, and we need to collectively think differently about this wicked problem.
Suicide prevention ideology over-focuses on eliminating “bad” or negative thinking and behavior. This conceptualization is contrary to science and common sense. The science says that telling people to stop engaging in unhealthy behaviors usually doesn’t work. When people are judged and told they should change, they often become defensive and more resistant to change. This is human nature.
All this brings me to share one strategy for moving beyond traditional suicide prevention. We should put more energy into growing and nurturing positive and meaningful thoughts and behaviors. People are more likely to change if they’re accepted for who they are, and then invited to try something interesting.
*End of Excerpt*
If you read the preceding and have a reaction, I’d love to hear your thoughts on how, with increasing suicide prevention focus, the suicide deaths keep increasing, and why, during the two worst years of COVID, suicide deaths decreased. Feel free to post on this blog or pop me an email.
This week, for the Montana Happiness Challenge, we’re focusing on adopting a mindset where we look for joy or for what inspires us. Last week I did a day-long training on Suicide Assessment and Treatment with professionals in Canada. At the end of the day, I was inspired that they took a full-day to learn about something so hard and challenging. Similarly, if you got through this whole blog because of your interest in making the world a better place, you inspire me.
If you want to keep up with the Montana Happiness Challenge, here are some clickable options:
Last week I did a little cliff-jumping into the Stillwater River with my twin 13-year-old grandchildren. It was only about 20 feet, but high enough to feel the terror and exhilaration of a brief free-fall.
This week I’m having a different kind of buzz. Dr. Margaret Rutherford reached out to me with a link to her TEDx Boca Raton talk. Previously I was a guest on her video podcast show (here’s the link to her podcast page: https://drmargaretrutherford.com/podcast-2-2/, and a link to her website and book, “Perfectly Hidden Depression” https://drmargaretrutherford.com/perfectlyhiddendepressionbook/). We’ve stayed in touch via email. Along with her link, she apologetically noted that she “barely” got a plug in for my work on strengths-based suicide assessment. I thought it was incredibly nice for her to give a nod, even a brief one, to my work. But then I watched and discovered that she had only mentioned three professionals: Edwin Shneidman (the “Father of Suicidology), Sidney Blatt (a renowned suicide and depression researcher from Yale), and some obscure guy from the University of Montana (that would be me).
Aside from feeling honored, humbled, and flattered to even get a mention, Dr. Margaret’s talk is fantastic. She makes the point–with a couple of articulate cases–for moving away from a strictly medical model perspective and toward working with people who may be suicidal through a lens of no judgment and acceptance. Here’s the link to her talk, which is well-worth a watch: https://www.youtube.com/watch?v=lXZ5Bo5lafA
There are other signs that how professionals (and hopefully the public) view suicidal ideation and behavior may be shifting toward greater acceptance. I’ll go into these other signs in a future post, but right now I want to emphasize that the point is not to replace the medical model, but to move the needle toward less pathologizing and more acceptance of the fact that having suicidal thoughts is often a normal part of life. To the extent that we can approach people who are thinking about suicide with, as Dr. Margaret said, “non-judgment and acceptance,” the more likely they are to be open with us about their pain. . . and . . . when people are open about their pain and suffering, then we have a chance to listen with empathy and a greater opportunity to be of help. . . which, I think, is the main point.
Tomorrow morning, March 31, 2023, at 8am, I’m co-presenting with Matt Englar-Carlson and Dan Salois on suicide and happiness with men at the American Counseling Association World Conference in Toronto.
Here’s the session blurb:
Men and boys account for nearly 80% of all suicide deaths in the U.S. Factors contributing to high suicide rates include: constricted emotional expression, reluctance to seek help, firearms, alcohol abuse, and narrowly defined masculinity. In this educational session, we will use a case demonstration to illustrate suicide assessment counseling methods to help boys and men liberate themselves from narrow masculine values, while embracing alternative and meaningful paths to happiness.
If you’re in Toronto, I hope to see you there. . . and for anyone interested, here’s the Powerpoint presentation:
Engaging clients in a collaborative safety planning process is an evidence-based suicide intervention. The typical gold standard for safety planning is the Safety Planning Intervention (SPI) by Stanley and Brown (2012). You can access free material on the SPI and learn how to obtain professional training for using SPIs at this link: https://suicidesafetyplan.com/
As a part of the 7.5-hour Assessment and Intervention with Suicidal Clients video published by psychotherapy.net, I did a short (about 7 minute) demonstration of safety planning with a 15-year-old cisgender female client. The demo comes at the end of the session and naturally, I already know lots of information that can be integrated into the safety plan. Nevertheless, introducing and completing the safety plan is an excellent organizing experience.
In part, safety planning emerged as an alternative to what were called “No-suicide contracts.” No suicide contracts fell out of favor in the mid-to-late 1990s, because many clients/patients viewed them as coercive and liability-dodging behaviors by clinicians, and because they focused on what NOT TO DO, instead of what clients/patients should do, when feeling suicidal. Safety planning involves proactive planning for what clients can do to effectively cope during a suicidal crisis.
Victor Yalom of psychotherapy.net has given me permission to offer this video clip to everyone as a free resource to guide and inspire you as you work to develop your skills for collaborative safety planning. You can find a glittering array of videos, including the previously mentioned, three-part 7.5 hour classic at: https://www.psychotherapy.net/ and https://www.psychotherapy.net/video/suicidal-clients-series
I’m in Helena today, learning and presenting at the Montana CBT Conference. This is a very cool event, organized by Kyrie Russ, M.A., LCPC, and including about 35 fantastic Montana professionals interested in deepening their knowledge of CBT principles and practice.
I’m presenting twice; below I’ve included links to my two sets of ppts (which may be redundant/overlapping with ppts I’ve posted here before).
Exploring the Potential of Evidence-Based Happiness
I’m in Enterprise, Oregon today and tomorrow morning. I got here Sunday evening after a winding ride through forests and mountains. Yes, I’m in Eastern Oregon. Even I, having attended Mount Hood Community College and Oregon State University, had no idea there were forests and mountains in Enterprise.
The scenes are seriously amazing, but the people at the Wallowa Valley Center for Wellness-where I’m doing a series of presentations on suicide assessment and prevention-are no less amazing. I’ve been VERY pleasantly surprised at the quality, competence, and kindness of the staff and community.
Just in case you’re interested, below I’m posting ppts for my three different presentations. They overlap, but are somewhat distinct.
Earlier this year I was asked by a school district to create and record a one-hour training on strengths-based suicide assessment. I made the recording, shipped it off, got paid, and mostly forgot about it. However, because I have the recording and sometimes I think it’s good to give things away, I’m sharing the link here: https://youtu.be/kLlkh8nJ2pI
The video is about 62 minutes, recorded on Zoom, and slightly oriented toward school counselors and school psychologists. I’m sharing this video just in case it might be useful to you in your teaching or for your clinical group or personal knowledge, etc. Feel free to share the link.
If you feel you benefit from this video, I hope you’ll consider the “pay it forward” concept. No need to pay me . . . just notice opportunities where you can share your gifts and talents and resources with others and pay it forward.
In honor of National Suicide Prevention Month, I’m offering another chunk of information about suicide assessment and treatment. This information is an excerpt from our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach. In the book, we discuss assessment and treatment planning using a dimensional approach. The first (and central) dimension for suicide assessment and treatment is the emotional dimension.
When clients are depressed and suicidal, everyone—including family, friends, co-workers, counselors, and clients—wish for an improved emotional state. But often the process is slow, and as a result, the very people upon whom the client relies for support may lose patience. Supportive people, even counselors, may feel urges to say things that are emotionally dismissive, like, “Cheer up” or “Come on, you need to exercise!” or “Why can’t you do something to make your life better?”
Moving clients out of despair and into the light is difficult; if it were otherwise, clients would resolve suicidality on their own. Directly or indirectly suggesting to clients in suicidal pain to “cheer up” often backfires, creating anger, hostility, and resistance to treatment; this resistance is a powerful phenomenon called, psychological reactance(Brehm & Brehm, 1981).
Psychological reactance occurs when clients perceive their ultimate freedoms as threatened. If clients sense that clinicians want to coerce them to stay alive, in response, they may dig in their heels and engage in behaviors designed to restore feelings of autonomy. Psychological reactance is one explanation for why clients who are suicidal sometimes vehemently resist help, insisting on their right to think about and act on suicidal impulses. Repeated empathic acceptance of the client’s emotional pain is one way to avoid activating reactance; empathic acceptance also allows clients to begin exploring and addressing key emotional issues in counseling.
Key Emotional Issues to Address
Many emotional issues are relevant to suicide treatment planning. These include: (a) excruciating distress, (b) specific disturbing emotions, such as, acute or chronic shame and guilt, anger, or sadness, and (c) emotional dysregulation. In this next section, we briefly review core emotional issues that you may guide your treatment planning. Later in the chapter we provide case examples and vignettes illustrating methods for working in the emotional dimension.
Excruciating Distress
Shneidman referred to the emotional state surrounding suicide as “psychache” or unbearable distress. He wrote: “The suicidal drama is almost always driven by psychological pain, the pain of negative emotions—what I call psychache. Psychache is at the dark heart of suicide; no psychache, no suicide.” (2001, p. 200, italics added).
Even when using a strength-based or wellness model, exploring the “pain of negative emotions” or excruciating distress is usually your first focus. Sometimes, to avoid activating reactance or resistance, you’ll need to stay with your client’s emotional pain longer than you’d prefer. Staying with your clients’ pain not only helps bypass resistance, it also models that facing negative affective states without fear, avoidance, or dissociation requires personal strength. Even so, as you focus on suicidal pain, you might wish the client would immediately adopt a more positive mindset, or find the process difficult to bear. You also might need to turn to colleagues or your self-care plan for support. Nevertheless, job one in the emotional dimension is to recognize and resonate with your client’s emotional pain.
Acute or Chronic Shame and Guilt
Shame and guilt are non-primary emotions because they involve significant self-reflection. Shame connotes beliefs of being unworthy, defective, or bad. Shame is often directly linked to core beliefs about the self, and activated by particular life situations. In contrast, guilt is more specific, often associated with certain actions or lack of actions (e.g., “I should be doing more to fight racism” or “I shouldn’t have been so critical of my professor”). Generally, guilt can lead to shame, and shame is more likely to ignite suicidality. Reducing or resolving shame or guilt may be a crucial therapeutic goal.
Suicidal thoughts are often accompanied by shame. Cultures around the world have historically judged death by suicide as a shameful or sinful event, and many still do. Your client’s experience may be something like, “Not only do I have suicidal thoughts—which are terrible in their own right—but the fact that these thoughts exist in my mind also make me a bad person.” This double dose of negative judgment, emotional pain plus self-condemnation, often needs to be addressed in counseling. One strategy that may fit into your treatment plan is to help clients develop greater self-compassion as a method for countering their self-condemnation.
Anger
In graduate school, we had a professor who suggested we consider this question: “Who is this client planning to commit suicide at?” Often, people who are suicidal carry great anger toward one or more friends, lovers, or family members and thus think of suicide as an act of revenge. Counselors should listen for underlying themes that involve using suicide as a behavioral goal for getting even or intentionally hurting others (Marvasti & Wank, 2013).
Thoughts of dying by suicide sometimes emerge as a revenge fantasy. Thoughts like, “I’ll show them” or “they’ll suffer forever” represent anger, along with the desire to punish others. It can be tempting to point out to clients that death is an irrationally high price for fulfilling revenge fantasies. However, helping clients express, accept, and understand the depth of their anger will usually reduce suicidality more efficiently than pointing out that death is a maladaptive revenge strategy. If revenge is central and forgiveness isn’t a viable option, then an apt philosophy to gently infuse into your clients is that the best revenge is a well-lived life.
Sadness
Major depression is the psychiatric diagnosis most commonly linked with suicide attempts, especially among older adults (Melhem et al., 2019). Clients who present with sadness as a dominant emotion may or may not meet diagnostic criteria for major depression. However, when sadness and the associated emotions and cognitions of irritability, regret, discouragement, and disappointment are central sources of distress, we recommend targeting those symptoms with evidence-based counseling interventions. Weaving positive psychology or happiness interventions into treatment planning is especially appropriate for clients struggling with sadness and depression (Seligman, 2018; Rashid & Seligman, 2018). More information about evidence-based approaches and positive psychology interventions is provided later in this chapter and in upcoming chapters.
Emotional Dysregulation
Clients who are suicidal may exhibit emotional dysregulation during counseling sessions and in their everyday lives. Clients may be emotionally labile, shifting from expressing anger to feelings of affection, appreciation, and deep connection. Clients may share stories of repeated maladaptive emotional overreactions to life’s challenges. Although unstable relationships, emotional swings, and explosive anger fit with the diagnostic criteria for borderline personality disorder, when clients are experiencing excruciating distress, they may behave in ways that resemble borderline personality disorder. However, instead of pathologizing clients with a personality disorder diagnosis, we recommend framing client behaviors using a social constructionist strength-based orientation, such as: Given enough situationally-based stress, including, as Linehan (1993) noted—emotionally invalidating environments—nearly everyone becomes dysregulated and appears unstable. Normalizing dysregulation as a natural response to intense distress helps maintain a strength-based perspective.
Treatment plans for clients who are suicidal often include teaching emotional regulation skills; this translates to helping clients become more capable of regulating themselves in the face of emotionally activating circumstances. Linehan’s (1993, 2015) protocols for working with clients with borderline personality characteristics are recommended for emotional regulation skill development. However, alternative approaches exist, some of which come from positive psychology, happiness, and well-being literature (Hays, 2014; Lyubomirsky, 2007, 2013; see Wellness Practice 4.1).
Rita has slipped away with a friend to go to a Tippet Rise (https://tippetrise.org/events/36201) concert. IMHO, Tippet Rise has amazing concerts. As a means to cope with my jealousy, I’ve decided to pass along a couple of freebies I found in my email inbox. Given that most of the freebies I receive in my inbox are related to someone who wants to trick me into becoming a few hundred million bucks richer, rest assured, I’ve screened out the fake-freebies, and have vetted these.
First, from Dr, Thomas McMahon of Yale University. He wrote about a free eBook:
Youth Suicide Prevention and Intervention offers a comprehensive review of current research on the public health crisis and best practices to prevent youth suicide. The volume was edited by John P. Ackerman, PhD from the Center for Suicide Prevention and Research at Nationwide Children’s Hospital and Lisa M. Horowitz, PhD, MPH from the National Institute of Mental Health. It includes 18 chapters organized into five sections on (a) foundations for suicide prevention, (b) prevention and postvention in school settings, (c) screening and intervention with suicidal teens, (d) prevention and intervention for special populations, and (e) the development of more effective systems of prevention.
With support provided by Nationwide Children’s Hospital Foundation and Big Lots Behavioral Health Services, the volume is available in an open access format. An electronic copy of specific chapters or the entire volume can be downloaded free of charge here.
Second, Amanda DiLorenzo-Garcia, Ph.D, of the University of Central Florida shared info about a free virtual symposium. Here’s what she wrote:
In honor of suicide prevention month, the Alachua County Crisis Center hosts a free mental health symposium. It is an incredible resource for counseling students, counselors, parents/guardians, teachers, first responders, etc. Therefore, it is open to the community at large.
This year the symposium is titled Holding Space Together: Addressing the Mental Health Needs of 2022. Topics vary and include suicide prevention, parenting, mindfulness, black mental health, burnout, tapping skills, ADHD, etc. The sessions will take place September 12-15th, 2022 between 5:30-8:30pm EST virtually. Sessions are facilitated by Alachua County Crisis Center staff, community agency mental health providers, and Counselor Education faculty from various institutions. The information is geared toward the general community; however, there are sessions that counselors and counseling students may benefit from attending as well.
That’s all for now. The book section is below. Have a great holiday weekend . . .
John S-F
Working in the Behavioral Dimension
When times are difficult and life feels intolerable, many people think about suicide as an alternative to life. But most individuals, despite intense emotional and psychological pain, don’t act on their suicidal thoughts. In fact, people often cling to life even in the face of great pain. Philosophers, suicidologists, and evolutionary biologists all point to the likelihood that humans are genetically predisposed toward survival (Glasser, 1998).
For a variety of biological, psychological, and environmental reasons, it’s usually easier to get people to experiment with new behaviors than it is to get them to stop engaging in their old, habitual behaviors. As children, you may have been repeatedly told “don’t smoke, don’t drink, don’t date that person, and don’t you dare miss your curfew again.” But often, those admonitions didn’t stick. Given how difficult it is to successfully get people to comply with prohibitions makes the “don’t act on suicide impulses” goal of this chapter an arduous task.
This chapter isn’t so much about telling people what not to do, as it is on helping them identify and act on alternative behaviors. Our aim is to stay primarily strength-based, helping clients flood their personal lives with positive behaviors. We’ll review and describe methods for building healthy behavior patterns, developing positive safety plans, and more.
Key Behavioral Issues to Address
The empirical research is thin, but several near-term predictors of suicidal behavior have been identified. These include: (a) active suicide planning or intent, (b) dispositional pain insensitivity and acquired suicide capability, (c) impulsivity, and (d) access to lethal means (Joiner, 2005; Klonsky & May, 2015; O’Connor, 2011).
Suicide Planning or Intent
Suicide ideation is common—especially among clients and students who are experiencing depressive symptom. But early everyone who thinks about suicide, chooses not to act on their thoughts.
Suicide planning is a step closer to action. When clients have suicide plans, their ideas have taken shape into potential behaviors. Typically, clients who have plans that include greater specificity, higher lethality, more accessibility, and less chance of being prevented are at higher risk. Nevertheless, most clients who have suicide plans don’t act on them.
Suicide intent—although still in the realm of thought—implies enactment of a plan. Suicide intent is especially disturbing when associated with repeated suicide attempts or rehearsal of specific suicide methods. Mentally rehearsing or physically practicing suicide behaviors makes the manifestation of those behaviors more likely. However, when intent is high, planning and rehearsing may not be required; given an opportunity, clients with extremely high intent may spontaneously and impulsively jump from moving cars, dash into heavy traffic, throw themselves into bodies of water, or find whatever means they can to end their lives.
Clients with high suicide intent sometimes require hospitalization and may need to be on safety watch. Pulling clients back from the suicidal edge and modifying their intent is frightening, but potentially gratifying. If you work with clients who have extremely high intent, remember to focus on your own safety and find support for potential vicarious traumatization.
Suicide Desensitization or Acquired Capability
Some individuals are unusually fearless and sensation-seeking from birth. O’Connor (2011) refers to this as dispositional pain insensitivity. In contrast, other individuals, born with normal pain sensitivity and a normal aversion to death can, over time, achieve what Joiner (2005) called acquired capability; this process is also called suicide desensitization. Joiner wrote: “The capability to act on (suicidal) desire is acquired over time through exposure to painful and provocative events” (2005, p. 3).
The predisposition to fearlessness and high pain tolerance likely has biogenetic roots (Klonsky & May, 2015). In such cases, psychosocial therapeutic strategies are limited. Identifying high-risk and high-vulnerability situations and activities and then working collaboratively with clients on appropriate coping strategies may be the best treatment option.
Clients who have acquired capability have become desensitized to suicide over time (Joiner, 2005). Desensitization can be unintentional or intentional. Repeated trauma or exposure to chronic physical pain can produce desensitization. Alternatively, self-mutilation and substance abuse and dependence are intentional behaviors that produce numbness and can reduce fear of pain and suicide.
Impulsivity
Clients who are highly impulsive tend to act suddenly, without planning, and without reflective contemplation. Impulsivity can be examined as a trait—individuals who display a pattern of acting without planning and do so across time and different circumstances have trait impulsivity. Impulsivity can also be situationally triggered; ingesting alcohol, being around certain people, or being in particular situations can magnify impulsivity.
Clients diagnosed with bipolar disorder, borderline personality disorder, and substance use disorders are more inclined toward impulsive behavior patterns and suicide. Effective treatments of impulsivity are limited. Some possibilities include (a) dialectical behavior therapy (Linehan, 1993), (b) lithium (Cipriani et al., 2013), and (c) individual or group treatment for substance abuse (López-Goñi et al., 2018).
Access to Lethal Means
Easy availability of lethal means increases suicide risk. Firearms are far and away the most lethal suicide method. Although firearms can quickly become a politicized issue, access to firearms unarguably magnifies suicide risk (Anestis & Houtsma, 2018). Other common and lethal suicide methods include poisoning (using pills or carbon monoxide) and suffocation/asphyxiation. Reducing access to lethal means or enhancing firearms safety are common strategies that reduce immediate suicide potential.
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John Sommers-Flanagan 