A Strengths-Based Approach to suicide Assessment, Intervention, and management

1. A Strengths-Based Approach to suicide Assessment, Intervention, and management Professional and Community Collaboration and Coping John Sommers-Flanagan, Ph.D., University of Montana Department of Counselor Education John.sf@mso.umt.edu or johnsommersflanagan.com

2. Hello from Montana, USA

3. Preparation • My favorite topic • Emotionally difficult, but emotionally important • Trigger warning: Rick story + breaks/self-care • INFORMED CONSENT – Are you ready?

4. Learning Objectives • Build Your Suicide Knowledge • Bust five BIG suicide myths • Deepen your understanding of the phenomenon of suicide (e.g., eight risk dimensions) • Articulate the pros, cons, and caveats of assessing suicide risk among students and clients

5. Learning Objectives II • Practice Suicide Assessment & Intervention Skills • Integrate eight suicide risk and strength dimensions into your suicide assessment and intervention process • Focus on skills for: (a) asking directly, (b) integrating positives, (c) social connection, (d) instilling hope, (e) dealing with irritability and agitation, (f) safety planning, (g) lethal means restriction, and (h) additional interventions.

6. Learning Objectives III • Develop Self-Awareness and a Positive Attitude Toward Suicide • Explore your attitudes toward and reactions to suicide • Imagine how you might cope with a completed suicide • Track, throughout the workshop, how learning about and practicing suicide assessment and intervention skills, affects you psychologically and emotionally

7. Learning Objectives IV 4.Explore Methods for Professional and Community Collaboration and Coping • Identify your own best collaborative strategies • Talk with communities and families about three simplified principles of crisis response • Find ways to advocate for at-risk populations

8. Our Ground Rules Include • Opennessto Learning • Commitmentto being Respectful • Willingness to Participate in Learning Activities • A commitment to SELF-CARE – 8+ Hours

9. And Remember • This is YOUR workshop • Your input and comments are welcome, not mandatory (I will keep us on track – more or less) • Let’s have as much fun as we can while learning together about a very challenging topic

10. Bust A Big Myth – I • Suicidal thoughts and gestures ARE SIGNS OF DEVIANCE • Nah: About 10% of human population will attempt suicide • And 20% will struggle with SI + SP • Up to 50% of teens are bothered by suicidal thoughts • Relax, NORMALIZE, and explore suicide ideation for what it is: an expression of distress

11. Bust A Big Myth – IA • “Green Party MP Chloe Swarbrick said the taboo around talking about mental health needs to change” from RNZ – 24 August 2018 • New Norms: • It’s normal to talk about stress, distress, mental health, and suicidal thoughts • It’s normal to seek help for mental health issues • It’s normal to listen to friends, family, acquaintances, and strangers with compassion and respect

12. Bust A Big Myth – II • When conducting assessments, we should look for pathology • Not so: That just makes students and clients feel worse about themselves • Your judgments increase the distance between you and your client • Instead: We acknowledge pain, while looking for and highlighting STRENGTHS

13. Bust A Big Myth – III • As professionals, we emphasize risk factor assessment and diagnostic interviewing • Nope . . . IS PATH WARM. . . SAD PERSONS • Suicide is unpredictable (< our preoccupation) • Instead, we work with students, parents, and clients to address unique risks and increase protection

14. Bust A Big Myth – IV • We are medical authorities who evaluate and [ELIMINATE] suicide ideation • Nyet:Linehan; we collaborate (CAMS) • Suicide contracts are out • Collaborative safety planning is in

15. Bust A Big Myth – V • Suicide is 100% preventable • Negatory: Suicide rates are mostly stable • Prevention efforts account for little (if any) variance in suicide rates • Your focus should be on making a difference to the person you’re sitting with. • 100% prevention messages make people guilty

16. Case – connie – family guilt • Connie is a 63-year-old talking about her ex-husband’s suicide from 4+ years previously • 03 - 57:20 – 59:04

17. Clinician Knowledge: Myth Busting

18. Practice Activity – Awareness • Let’s imagine an unpleasant scenario together • Survey Questions (How many of you have . . .?) • Focus, briefly now, on the possibility of having a client die by suicide

19. Practice Activity – Reflections • Talk with your table about: • What you felt in your body, and where • What thoughts passed through your mind? • What emotions did you experience? • Anything else triggered?

20. Reflections II • Suicide is probably the biggest stressor that clinicians (and humans?) face • Anxiety and irritation [waste of time] • Practice is essential! • But practicing will be triggering • Ongoing: What are your BELIEFS about suicide?

21. Knowledge • Now let’s intellectualize • In 1949, Edwin Shneidman, a suicidology pioneer . . . • Discovered several hundred suicide notes in a coroner’s vault • But did not read them

22. Knowledge II • Consequently, he discovered “Psychache” • “In general, it is probably accurate to say that suicide always involves an individual’s tortured and tunneled logic in a state of inner-felt, intolerable emotion.”

23. Knowledge III • “No psychache. No suicide.” • “The central issue in suicide is not death or killing” • Psychache (aka psychological pain or unbearable distress) is the primary focus of treatment. • What makes for unbearable distress is unique across individuals, cultures, settings, etc.

24. Knowledge iV Base Rates Death by suicide is alarming, but infrequent: In NZ: 13.67/100,000, up from 12.64 in 2017; down from 15.1 in 1998 Highest rates among Māori (NZ) and Native Americans (US): about 22/100,000 Whites: suicides rise with age; indigenous peoples = opposite In NZ: Rates are up for 4 consecutive years; US, for 12 years

25. Knowledge V Base Rates The math: Let’s say major depressive disorder increases risk by 25x. 13.67 x 25* = 341 per 100,000 or 0.341% or 1 of every 293 New Zealanders with MDD All 293 have MDD, which one will die by suicide in the next year? The answer: We don’t know.

26. Risk Factors -- Critique • There are NO GOOD RISK FACTORS (Spring) • You can’t accurately predict suicide based on risk factors • Risk factors must be individualized

27. Knowledge VI • There are NO GOOD RISK FACTORS: Examples 25+ . . . But they can also protect • New SSRIprescription; Previous attempts; Cutting • Illness; Male; Insomnia + hopelessness; Depression with Panic • Remember: No predictors substitute for a good suicide assessment interview with follow up [Individualize!]

28. Shawn Shea on Risk and Protective factors • https://www.youtube.com/watch?v=MCqlLCR5mEs • 9:56-10:50 • Conclusion: You can’t predict, but denial + high risk factors and you should contact a third party

29. Knowledge VIi: 8 Risk Dimensions • Intolerable or unbearable distress [The core] • Social disconnection [thwarted belonging or perceived burden] • Hopelessness [“nothing helps”] • Arousal or agitation [diminished self-control] • Intent and/or planning [movement toward] • Desensitization [alcohol; drugs; cutting] • Problem-solving deficits [mental constriction] • Lethal means available [firearms U.S. NZ, strangulation/suffocation]

30. PLUSH AID: 8 Risk Dimensions • Problem-solving deficits [mental constriction] • Lethal means available [firearms U.S.; NZ, strangulation/suffocation] • Unbearable or intolerable or distress [The core: Psychache] • Social disconnection [thwarted belonging or perceived burden] • Hopelessness [“nothing helps”] • Arousal or agitation [diminished self-control] • Intent and/or planning [movement toward] • Desensitization [alcohol; drugs; cutting]

31. Case – Kennedy 1 – Opening • Kennedy is a 15-year-old referred by her parents • This is session #1: 1:38 – 5:04 • Watch for: (a) first mention of suicide; (b) first focus; (c) problem-solving; (d) “gun” mention; (e) the risk dimensions

32. Kennedy – 1 – Discussion • First mention of suicide – Parents/Others • First focus (Distress . . . Why?) • Problem-solving • Gun mention • The risk dimensions

33. Asking About Suicide: Three skills • Use a NORMALIZING FRAME • Use GENTLE ASSUMPTION • Use MOOD SCALING WITH A SUICIDE FLOOR

34. Skill 1: Normalizing Frame • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you? • Most people who are feeling down think about suicide from time to time. Have you had thoughts about suicide? • Practice

35. Skill 2: Gentle Assumption • Don’t ask: “Have you thought about suicide?” • Ask: “When was the last time you thought about suicide?” • For use in an E.R. setting

36. Case – Kennedy 2 – Mood scaling Demo of Mood Scaling with a Suicide Floor 13:37 – 17:07

37. Kennedy – 2 – Discussion • What did you learn about Kennedy? • I went to problem-solving – why? • PS is BOTH . . . and • Where else could you take the Mood Scaling?

38. Mood scaling Practice • May I ask some questions about your mood? • Rate your mood, using a zero to 10 scale. Zero is the worst mood possible. Zero means you’re totally depressed and so you’re just going to kill yourself. A 10 is your best possible mood. A 10 would mean you’re as happy as you could be, maybe dancing or singing or doing whatever you do when you’re extremely happy. Using zero to 10, what rating would you give your mood right now? • What’s happening now that makes you give your mood that rating? • What’s the worst or lowest mood rating you’ve ever had? What was happening to make you feel so down? • For you, what would be a normal mood rating on a normal day? • What’s the best mood rating you’ve ever had? What was happening that helped you have such a high mood rating?

39. Mood scaling – reflections Be with your supportive table partners and discuss: • What thoughts and feelings did the mood rating bring up for you? • What problems did you feel/encounter? • How might you use it (variations)?

40. Problems with Scaling • The scale is more subjective than objective • A 3 for me may not equal a 3 for you • A 9 may be linked to suicide ideation • Try to ground the scale deep in your clients’ experiences • Focus on what triggers downward AND upward movement [with or without numbers]

41. Balance Strategy • Don’t just ask about depression and risk. • Also ask about protective factors and strengths • What has helped before? • Hopes for today, tomorrow, etc. • When is your sadness gone? • What helps you concentrate, sleep? • What brings a little light into the darkness?

42. Case – Chase – Assessment • Chase is a Gay male with a history of suicidality • This is the beginning of session #1: 1:05:51 – 1:10:08 • Watch for: (a) Asking directly; (b) normalizing; (c) the risk dimensions; (d) asking permission

43. Chase – Discussion With your table discuss: • How you felt/reacted to John asking directly so early • What risk dimensions do you immediately see • Remember, the risk dimensions point to interventions . . . where do Chase’s point?

44. Interventions • Interpretation [Common patterns] • Social Universe (or Network) • Dealing with Hopelessness and Irritability • Alternatives to Suicide • The Existential Question • Collaborative Safety Planning • Neodissociation

45. Chase – Social Universe Intervention • Chase described two toxic people in his life • Show Chase Clip 1:15:23 - 1:20:01 then 1:21:45 – 1:24:34

46. Chase – Social Universe II • Interpretation: Common thread • How might you use this social universe assessment therapeutically? • Note the building of a continuum from the bottom up • What does John do poorly at the end?

47. Irritability/Hopelessness Role Play • Volunteer Needed!

48. Irritability Strategy • Reflection: “I hear annoyance in your voice” • Light Interpretation: “That might be because irritability is part of being depressed” • Commitment Statement: “I want to know when I annoy you. I also want to know when I say things that are helpful. I want to work with you and be less annoying and more helpful.” • Stay Centered: Take nothing personally, but be authentic • Repair: Apologize if you said something offensive

49. Hopelessness Strategy • Hopelessness Reflection: “I hear you saying that, right now, you feel completely miserable and hopeless” • Match Language and Explore: “Do you mind telling me more about what’s feeling shitty right now?” • Validate: “It’s natural . . .” • Start From the Bottom: “What makes it worst?”

50. Case – Cory – Cultural Issues • Show Cory Clip – 1:40:44 – 1:46:14 • What has Cory shared with us about his culture? • What risk dimensions seem prominent?