Suicide Prevention: Knowledge, Attitudes, Skills

1. suicide Prevention in three Parts: Knowledge, Attitudes, Skills John Sommers-Flanagan, Ph.D. University of Montana Department of Counselor Education John.sf@mso.umt.edu or johnsommersflanagan.com

2. Opening • Ironically happy, but • Rick walk out story • Please take care of yourselves and talk • SO CRUCIAL TO TALK DIRECTLY ABOUT THIS TOPIC

3. The Problem of Suicide

4. Learning Objectives • Provide information about suicide theory, a suicide assessment model, and clinical practice • Identify core attitudes for working effectively with suicidal students/clients • Describe and practice specific skills for suicide assessment and interventions

5. Opening II • 1991 Story • Guilt and regret • Big suicide-related myths from the Med Model • Thoughts and impulses = deviance • Job = assess, intervene, and eliminate SI

6. What I wish I’d known • This Medical Model thinking is unhelpful • Creates distance, takes power away, and makes student/clients feel crazier • Time to BUST THE BIG MYTH • SI NOT a sign of deviance, but normal distress • No need to freak out; let’s talk about suicide

7. what we know about base rates Death by suicide is infrequent: 13.4/100,000 But suicide attempts are not infrequent (10%) Suicide ideation (SI) is common (up to 50%) This makes suicide prediction very difficult, but experiencing SI is not an illness

8. Preparation • 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

9. Preparation II • And he discovered “Psychache” • Great quotation: “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. In addition, this mixture of constricted thinking and unbearable anguish is infused with that individual’s conscious and

10. Preparation III • . . . unconscious psychodynamics (of hate, dependency, hope, etc.), playing themselves out within a social and cultural context, which itself imposes various degrees of restraint on, or facilitations of, the suicidal act”

11. Preparation IV • Why Suicide: Suicide Theories • Shneidman (psychache + mental constriction + perturbation) • Joiner (interpersonal theory—thwarted belongingness and perceived burden)

12. Suicide Interview Model 1. Suicide risk (and protective) factors 2. Suicide ideation 3. Suicide plan (SLAP) 4. Self-control and agitation 5. Suicide intent and reasons for living 6. Safety planning and other suicide interventions • S6 or R-I-P-SC-I-P

13. Risk Factors • There are 25+ and many acronyms to remember them • IS PATH WARM; SAD PERSONS SCALE • Big predictors include (a) previous attempt, (b) depression+, and (c) veteran status • Remember: No predictors substitute for a good suicide assessment interview

14. Risk Factors -- Critique • There are NO GOOD RISK FACTORS (Spring) • No research indicates they can predict suicide • Don’t get hung up on these; their best use is to inform us about potential suicide dynamics [For empathy] • The math: 13.4 x 25 = 335 per 100,000 or 0.00402% or 1 of every 249 patients with MDD

15. Risk Factors – Critique II • Stay Balanced with Protective Factors and Strength Focus • When depressive symptoms are gone • What has helped before? • Hopes for today, tomorrow, etc. • What helps you concentrate, sleep? • What brings a little light into the darkness?

16. Suicide Ideation Ask directly Use the word “suicide” when talking about confidentiality Use the word “suicide” when asking about suicide (not: “harm to self”) Frame the question: Asking “Have you been thinking about suicide” is okay, but we can do better.

17. Skill 1: Frame the Question (Attitude) • I’ve read that up to 50% of college students have thought about suicide at one point or another. Is that true for you? • Most people who are feeling down think about suicide. Have you had thoughts about suicide?

18. Remembering Carl Rogers • Genuineness • Postive Regard or Acceptance • Empathic Understanding

19. Skill 2: Use Shea’s Gentle Assumption • Don’t ask: “Have you thought about suicide?” • Ask: “When was the last time you thought about suicide

20. Skill 3: Mood Assessment with a Suicide Floor • Demo: Is it okay if I ask some questions about your mood? (volunteer) • On a scale from 0 to 10, where 0 means you’re so depressed you’re just going to kill yourself and 10 means you’re the happiest a human could possibly be and possibly dancing or whatever you do when VERY happy, how would you rate your mood right now?

21. Assessing Suicide Plans • SLAP the PLAN S – Specificity of the plan L – Lethality of the plan A – Availability of the means P – Proximity of social support

22. Self Control and Agitation • History of loss of control? • Self-reported sense of control? • Psychomotor agitation? • SSRIs in past 30 days and akasthisia?

23. Suicide Intent (and RFL) • Self-report of intent • Reasons for living • Goal = Diminish psychache (misery) or the self • You can ask directly about that as an intervention

24. Safety Planning • There’s no substitute for the safety plan • This is where you work collaboratively on identifying individual warning signs, coping responses, social distractions, support networks, and environmental safety (e.g., firearms)

25. Two Suicide Interventions • Explore alternatives to suicide • Neodissociation

26. Decision-Making • Frequency, intensity, and power of SI • Specificity and lethality of plan • Other risk and protective factors • Self-control and intent • Responsiveness to interventions, including the safety plan • Consultation and documentation

27. Traditional vs. Postmodern Suicide Assessment and Intervention Old Narrative: Checklist: We look for pathology, emphasize diagnostic interviewing, and no-suicide contracts New Narrative: We look for strengths, normalize suicide ideation, and initiate collaborative safety planning

28. Remembering Main Points • No more big myth: Now SI is a normal expression of distress • Collaborate with clients: I want you to live • Remember risk factors are poor specific predictors • Use sophisticated questioning skills (Frame, GA, Ratings) • Balance risk assessment with strength-based questions • Use safety planning, NOT suicide contracts • AND – Consult and Document • For info: Sommers-Flanagan & Sommers-Flanagan (2014). Clinical Interviewing (5th ed.). Chapter 9 or johnsommersflanagan.com

29. Self-Care • Helpful “Pit Check” • We need that • How am I doing? • Check up, check in, and check on • Take very good care of ourselves – stressful to face alone

30. Check up and Check -in

31. Reminds me • The mind is a terrible place to go . . . Alone • Which is why we should keep on talking—directly to each other and to our clients—about suicide and suicide prevention.