Advances in Suicide Assessment and Treatment Planning

1. Advances in Suicide Assessment and Treatment Planning Presented in Collaboration with the Big Sky Youth Empowerment Program John Sommers-Flanagan, Ph.D., University of Montana Department of Counselor Education John.sf@mso.umt.edu or johnsommersflanagan.com

2. Preparation • Emotionally challenging topic: Trigger warning • Opening story • BIG learning goal – Prepare to work with suicidal clients with courage and humility. • Questionnaires/quizzes!

3. Learning Strategy • Fill out informed consent for research (optional) • Complete part one of research packet (15-20 min) • Participate and learn today • Complete part two of research packet (20 min), to help with learning consolidation • Sign up to participate in optional 4 month follow-up • Continue learning independently and together

4. CaveatS and Disclaimers • The American Association of Suicidology (AAS) has 24 competencies under eight domains • Granello wrote of 25 strategies and 12 principles • Jobes, Joiner, Shneidman, Maris, Linehan, etc. • New learning will continue tomorrow!

5. Caveats and Disclaimers • The information provided today is based on research and clinical wisdom. I hope it will help you in your work. • As mental health professionals, you’re responsible for the application of this and other educational and training experiences into your work. • By attending today, you agree you will not hold the presenter responsible for any adverse outcomes that might be associated with this course material.

6. Learning Objectives • Develop greater self-awareness and a more positive attitude toward working with clients or patients who are suicidal. • View suicide ideation disclosures as positive • Feel more comfortable and competent • Articulate basic ethical issues • Track your emotional responses to learning about and practicing suicide assessment and intervention skills

7. Learning Objectives • Build your suicide knowledge • Bust problematic suicide myths • Review risk/protective factors and warning signs • Understand limits of risk/protective factors and warning signs • View suicidality as manifest within six life domains • Develop greater cultural sensitivity

8. Learning Objectives III • Practice suicide assessment, intervention, and treatment planning skills • Integrate six suicide life domains into your suicide work • Practice and learn many different assessment and intervention skills

9. Our Ground Rules Include • Be open to learning • Communicate respectfully • Engage in experiential activities to whatever extent you are comfortable • Take care of yourself as we learn together (6.5 hours) and beyond

10. And Remember • This is YOUR workshop • Your input and comments are welcome, not mandatory (I will keep us on track – more or less)

11. Clinician Attitude • Suicide is probably the biggest stressor that clinicians face • Anxiety and irritation [waste of time] • Practice is essential! • But learning and practicing is triggering • Ongoing: What are your reactions to and BELIEFS about suicide?

12. Activity – Awareness • Let’s imagine a scenario • You’re doing counseling • You need to ask about suicide • Tommie, 18 y/o Yupik tribe – 14:14 to 15:15 • https://players.brightcove.net/624142947001/r1evdKsni_default/index.html?videoId=5095441194001

13. Practice Activity – Reflections • Talk with your table about client suicide disclosures: • What do you feel in your body, and where • What thoughts and emotions do you experience? • What helps you cope?

14. Clinician Attitude • We WANT clients to disclose suicide ideation. Why? • We cannot help, if we do not know • We have skills to help clients deal with SI • And so we convey our confidence, competence, and comfort with this important issue • SI isn’t even a good predictor of suicide • Set aside all of our moral and philosophical quirks

15. Clinician Knowledge: Myth Busting

16. A Strength-Based Model • What makes this a strength-based model? • We no longer embrace the illness-oriented medical role of authoritative evaluator who knows what’s best and whose job is to eliminate suicide ideation and behaviors • We believe deeply in our hearts in acceptance and not pathologizing; we collaborate; we intentionally focus on strengths and balance our assessment questions.

17. Back to Risk/Protective FActors • Why?? • We may work in a setting that requires risk categorization • We may need to involuntarily hospitalize • Still proceed as collaboratively as possible

18. Categorizing Risk • Sometimes we need to do this • None:No risk and no need for suicide in treatment plan • Mild: Minimal risk. Managed with weekly monitoring and an emergency plan. Make sure firearms and lethal means are safely stored. • Moderate: Manage with an active safety plan. Engaging family/friends may be advisable. Make sure firearms and lethal means are safely stored. • High: Treatment will be hospitalization and/or an intensive safety plan implemented with family/friends. Firearms and lethal means are safely stored.

19. Risk Assessment Rules (Handout) • Risk Factors and Warning Signs: Generally, more risk factors and warning signs equals more risk. Factors that are particularly salient include: • 2+ previous attempts • Command hallucinations (e.g., “You must die”) • Severe depression, plus agitation and hopelessness • Preparation, planning, rehearsal behaviors (e.g., stockpile, giving away items) • Feeling trapped in immense shame, self-hatred, and excruciating distress • Protective Factors: Relationships, hope, engagement in meaningful activities, responsiveness to therapy/treatment • Consultation: Isolation can be contagious; don’t isolate yourself • Documentation: Include relevant assessment data, consultation results, and rationale for decision-making on level of care.

20. Robust theory/research Organization • Cognitive or Mental [Mental constriction, “nothing helps”] • Emotional [Core: Excruciating distress] • Social [Social disconnection or perceived burden] • Physical/Neurological [Agitated, impulsive, ill, and drugs] • Heritage/Spiritual/Cultural [Meaninglessness] • Behavioral [Suicide plan/intent, lethal means available]

21. Our Destination

22. Case – Kennedy 1 – Opening • Kennedy is a 15-year-old referred by her parents for depression/suicide ideation • 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 domains

23. What did we learn about Kennedy?

24. Treatment Planning • Our goal is to turn the 6 domains into a positive, strengths-oriented treatment plan. • Let’s look at our 6 domains treatment planning handout. • My focus with Kennedy was on HEAD (problem-solving) and HEART (distress)

25. Assessment: Process and skills First step: Asking about suicide ideation • Use a normalizing frame • Use gentle assumption • Use mood scaling with a suicide floor • Use balanced questions

26. 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 feel down think about suicide from time to time. Have you had thoughts about suicide? • Practice these or similar words

27. Skill 2: Gentle Assumption • Don’t ask: “Have you thought about suicide?” • Instead ask: “When was the last time you thought about suicide?” • Especially for use in emergency settings (Shea)

28. Skill 3: Mood Scaling • May I ask some questions about your mood? • Demo • Practice

29. Mood scaling Practice • 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?

30. 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)?

31. 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]

32. Kennedy – Mood scaling Skill Demo of Mood Scaling with a Suicide Floor 13:37 – 17:07

33. Kennedy – Discussion • What did you learn about Kennedy? [Let’s look at our Treatment Planning Handout] • I went back to problem-solving – why? • PS is BOTH . . . And . . .

34. Skill 4: Strength-Focused Questioning • Don’t just ask about depression and risk. • 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?

35. Domains and Assessments/Interventions

36. Irritability Role Play • Volunteer Needed!

37. Irritability Protocol • Reflection: “I hear annoyance in your voice” Wait for response. • Light Interpretation: “I don’t blame you for being annoyed or irritable. I’m sure meeting with me isn’t very fun. Also, it’s totally natural for people to feel irritable sometimes, especially if you’ve been feeling down.” • Commitment Statement: ““You can be as irritable as you want to be in here. My plan is to keep on working with you. You don’t have to worry about being polite or nice.” • Stay Centered: Take nothing personally, but be authentic • Repair: Apologize if you said something offensive

38. Chase – Assessment skills • 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 domains; (d) asking permission = ?

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

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

41. social Universe Skill • 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?

42. Hopelessness Role Play • Volunteer Needed!

43. Hopelessness protocol • 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?”

44. Cory – Cultural Issues • Show Cory Clip – 1:40:44 – 1:46:14 • What has Cory shared with us about his culture? • What seems culturally unique?

45. Cory 2 • Show Cory Clip – 1:48:01 – 1:54:48 • Five minute reflection: • What are you hearing from Cory? • What are the disrupted life domains? • What are the treatment targets? • What are the cultural issues/challenges?

46. Passive SI existential Intervention skill • Active and Passive SI are not the same and warrant different interventions • Show Jeanne Clip 1 – 1:07:30 – 1:12:00 • Show Jeanne Clip 2 – 1:19:20 – 1:23:08

47. Table Talk • Do the existential 6 months to live intervention with each other • Debrief: Thoughts, feelings, impulses, other?

48. Alternatives to Suicide Skill • Shneidman Story • Kay Clips: 1:50:02:23 – 2:00:28:06 • Discuss along the way

49. Separating pain From self Skill • Role Play • Debrief – What are the therapeutic benefits and liabilities of this intervention? • Battling Unbearable Distress

50. Kennedy – safety Planning skill • Collaborative safety (crisis) planning: • 34:32 – 39:03/39:59 – 43:27 • This involves collaborative work on identifying individual warning signs, coping responses, social distractions, support networks, and environmental safety (e.g., firearms)