Suicidality

1. Suicidality Anna Lieber, CMHC, NCC/CCMHC UMHCA Fall Conference October 18, 2019

2. Suicidal Behavior Among Adults (18+), United States 2017 45,390 Suicide Deaths 547,000 Hospitalized Overnight or Longer for a Suicide Attempt* 768,000 Received Medical Attention for a Suicide Attempt* 1,388,000 Suicide Attempts* *Self-Report Source: CDC WONDER, 2017; National Survey of Drug Use and Health, 2017

3. https://youtu.be/18vnsyDE-W8

4. Suicidal Thoughts and Behavior Among Adults (18+), United States 2018 3.3 Million Made Serious Plans 1.4 Million Attempted Suicide 10.7 Million Had Serious Thoughts of Suicide in the Past Year 1.2 Million Made Plans and Attempted Suicide 0.2 Million Did Not Make Plans and Attempted Source: National Survey of Drug Use and Health, 2018

5. Ideation to Action Framework & 3ST Low connectedness to life (i.e. purpose, social connections, feeling like a burden to others) & Capability Suicide Attempt Klonsky, D. & May, A. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy. 8(2) 114-129.

6. Why do people have suicidal thoughts? ……and how does that make us (therapists) feel?

7. Common Emotional Reactions when working with suicidal clients • Fear • Anger • Helplessness • Hopelessness If unchecked our emotions may cause: • Under-responsiveness • Hyper-responsiveness Undesirable outcomes • Triggering suicidal behavior • Keeping suicidal behavior a secret • Damage to therapeutic alliance • Client withdrawal

8. Working with an individual experiencing suicidal ideation • Phenomenology of Suicide = understanding as it is experienced by those who live it • Ambivalence is always present – lean into the inner conflict • Validate the suicidal thoughts & feelings • Assess current intensity • Dilemma with suicide (and conflict): “The therapist’s goal is to prevent suicide and the client’s goal is to eliminate pain & suffering via suicidal behavior.” • Collaboratively set a goal to decrease suffering • Make a new goal to embrace life • Focus on living not preventing death

9. Establishing a Shared Perspective

10. Assessment of Suicide Risk: From Prediction to Prevention Pisani, A., Murrie, D., & Silverman, M. (2015). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry .

11. Risk Assessment

12. Techniques for Eliciting Suicide Ideation, Intent, Plans & Behavior: • Normalization • “Sometimes when people feel this much pain, it is not unusual for them to wish they could be dead. Have you had thoughts like this?” • Shame Attenuation • “With all the suffering in your life, has it crossed your mind to kill yourself?” • Behavioral Incident • Ask about specific facts/details and thoughts • “What happened next?” • Gentle Assumption • “What other ways have you thought of killing yourself?” • Symptom Amplification • “On the days when you are feeling the most suicidal, how much time do you spend thinking about killing yourself, 70, 80 or 90% of the day?” • “How many pills did you take….100 pills or more?” • Ask about other plans/behaviors • “What’s your confidence in your plan?” • “What is the closest you have come to killing yourself?” “What was going on at that time?” • Safety Plan (not contracts) • Assess Reason for living = dig into the ambivalence and smallest of hope

13. Video – Linehan Stress Model

14. Crisis & Safety Planning / Crisis Response Plans

15. Care of the Clinician • Therapeutic Teams • Self-care • Boundaries • We will make mistakes It is only through our own practice of self-compassion that we will be able to express compassion for individuals with suicidal behavior

16. References & Resources • Blasco-Fontecilla, H., Baca-Garcia, E., Dervic, K., Perez-Rodriguez, M., Saiz-Gonzalez, M., Saiz-Ruiz, J., . . . de Leon, J. (2009 119). Severity of personality disorders and suicide attempt. Acta Psychiatr Scand, 149-155. • Houston, M. (2017). Treating suicidal clients & self-harm behaviors. Eau Claire, WI. PESI, Inc. • Klonsky, D. & May, A. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy. 8(2) 114-129. • https://livethroughthis.org/ • Pisani, A., Murrie, D., & Silverman, M. (2015). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry . • Webb, D. (2002). The many languages of suicide. Suicide Prevention Australia Conference. Sydney, June 2002. • Weding, M., Silverman, M., Frankenburg, F., Bradford Reich, D., Fitzmaurice, G., & Zanarini, M. (2012 Vol. 42 ). Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychological Medicine, 2395-2404. • Yen, S., Shea, T., Pagano, M., Sanislow, C., Grilo, C., McGlashan, T., Skodol, A., Bender, D., Zanarini, M. & Gunderson, J. (2003 Vol. 112) Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study. Journal of Abnormal Psychology. 375-381 • https://thinkingaboutsuicide.org/phenomenology-of-suicidality/ • www.sprc.org • http://www.mentalhealthamerica.net/ • https://afsp.org • https://www.nimh.nih.gov/health/statistics/personality-disorders.shtml • https://zerosuicide.sprc.org/about

17. Anna Lieber, CMHC, NCC/CCMHCDirector of Clinical ServicesSalt Lake Behavioral Health 801-264-6003Anna.lieber@uhsinc.com