A STRENGTHSBASED APPROACH TO SUICIDE ASSESSMENT INTERVENTION AND

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

HELLO FROM MONTANA, USA

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

LEARNING OBJECTIVES 1. 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

LEARNING OBJECTIVES II 2. 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.

LEARNING OBJECTIVES III 3. 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

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

OUR GROUND RULES INCLUDE Ø Openness to Learning Ø Commitment to being Respectful Ø Willingness to Participate in Learning Activities Ø A commitment to SELF-CARE – 8+ Hours

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

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

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

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

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

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

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

CASE – CONNIE – FAMILY GUILT 1. Connie is a 63 -year-old talking about her exhusband’s suicide from 4+ years previously 2. 03 - 57: 20 – 59: 04

CLINICIAN KNOWLEDGE: MYTH BUSTING Old Myth or Method We view suicide ideation as deviance When conducting assessments, we should look for pathology We emphasize risk factor assessment and diagnostic interviewing New Narrative and Approach We normalize SI, viewing it as a communication of distress or psychache We look for strengths We recognize risk factors and diagnosis are nearly irrelevant – except for in the unique context of our student or client We implement treatments on We engage clients empathically in clients and establish no-suicide a collaborative process of

PRACTICE ACTIVITY – AWARENESS Ø Let’s imagine an unpleasant scenario together Ø Survey Questions (How many of you have. . . ? ) Ø Focus, briefly now, on the possibility of having a client die by suicide

PRACTICE ACTIVITY – REFLECTIONS Ø Talk with your table about: Ø What you felt in your body, and where Ø What thoughts passed through your mind? Ø What emotions did you experience? Ø Anything else triggered?

REFLECTIONS II Ø 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?

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

KNOWLEDGE II Ø Consequently, he discovered “Psychache” Ø “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. ”

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

KNOWLEDGE IV Ø 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

KNOWLEDGE V Ø Base Rates • The math: Let’s say major depressive disorder increases risk by 25 x. • 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.

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

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

SHAWN SHEA ON RISK AND PROTECTIVE FACTORS • https: //www. youtube. com/watch? v=MCql. LCR 5 m. Es • 9: 56 -10: 50 • Conclusion: You can’t predict, but denial + high risk factors and you should contact a third party

KNOWLEDGE VII: 8 RISK DIMENSIONS 1. Intolerable or unbearable distress [The core] 2. Social disconnection [thwarted belonging or perceived burden] 3. Hopelessness [“nothing helps”] 4. Arousal or agitation [diminished self-control] 5. Intent and/or planning [movement toward] 6. Desensitization [alcohol; drugs; cutting] 7. Problem-solving deficits [mental constriction] 8. Lethal means available [firearms U. S. NZ, strangulation/suffocation]

PLUSH AID: 8 RISK DIMENSIONS 1. Problem-solving deficits [mental constriction] 2. Lethal means available [firearms U. S. ; NZ, strangulation/suffocation] 3. Unbearable or intolerable or distress [The core: Psychache] 4. Social disconnection [thwarted belonging or perceived burden] 5. Hopelessness [“nothing helps”] 6. Arousal or agitation [diminished self-control] 7. Intent and/or planning [movement toward]

CASE – KENNEDY 1 – OPENING 1. Kennedy is a 15 -year-old referred by her parents 2. This is session #1: 1: 38 – 5: 04 3. Watch for: (a) first mention of suicide; (b) first focus; (c) problem-solving; (d) “gun” mention; (e) the risk dimensions

KENNEDY – 1 – DISCUSSION 1. First mention of suicide – Parents/Others 2. First focus (Distress. . . Why? ) 3. Problem-solving 4. Gun mention 5. The risk dimensions

ASKING ABOUT SUICIDE: THREE SKILLS 1. Use a NORMALIZING FRAME 2. Use GENTLE ASSUMPTION 3. Use MOOD SCALING WITH A SUICIDE FLOOR

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

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

CASE – KENNEDY 2 – MOOD SCALING Demo of Mood Scaling with a Suicide Floor 13: 37 – 17: 07

KENNEDY – 2 – DISCUSSION 1. What did you learn about Kennedy? 2. I went to problem-solving – why? 3. PS is BOTH. . . and 4. Where else could you take the Mood Scaling?

MOOD SCALING PRACTICE • May I ask some questions about your mood? • What’s happening now that makes you give your mood that rating? • 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 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?

MOOD SCALING – REFLECTIONS Be with your supportive table partners and discuss: 1. What thoughts and feelings did the mood rating bring up for you? 2. What problems did you feel/encounter? 3. How might you use it (variations)?

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

BALANCE STRATEGY Ø Don’t just ask about depression and risk. Ø 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?

CASE – CHASE – ASSESSMENT 1. Chase is a Gay male with a history of suicidality 2. This is the beginning of session #1: 1: 05: 51 – 1: 10: 08 3. Watch for: (a) Asking directly; (b) normalizing; (c) the risk dimensions; (d) asking permission

CHASE – DISCUSSION With your table discuss: (a) How you felt/reacted to John asking directly so early (b) What risk dimensions do you immediately see (c) Remember, the risk dimensions point to interventions. . . where do Chase’s point?

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

CHASE – SOCIAL UNIVERSE INTERVENTION Ø Chase described two toxic people in his life Ø Show Chase Clip 1: 15: 23 - 1: 20: 01 then 1: 21: 45 – 1: 24: 34

CHASE – SOCIAL UNIVERSE II Ø Interpretation: Common thread Ø How might you use this social universe assessment therapeutically? Ø Note the building of a continuum from the bottom up Ø What does John do poorly at the end?

IRRITABILITY/HOPELESSNESS ROLE PLAY Ø Volunteer Needed!

IRRITABILITY STRATEGY 1. Reflection: “I hear annoyance in your voice” 2. Light Interpretation: “That might be because irritability is part of being depressed” 3. 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. ” 4. Stay Centered: Take nothing personally, but be authentic 5. Repair: Apologize if you said something offensive

HOPELESSNESS STRATEGY 1. Hopelessness Reflection: “I hear you saying that, right now, you feel completely miserable and hopeless” 2. Match Language and Explore: “Do you mind telling me more about what’s feeling shitty right now? ” 3. Validate: “It’s natural. . . ” 4. Start From the Bottom: “What makes it worst? ”

CASE – CORY – CULTURAL ISSUES Ø Show Cory Clip – 1: 40: 44 – 1: 46: 14 Ø What has Cory shared with us about his culture? Ø What risk dimensions seem prominent?

CASE – CORY 2 Ø Show Cory Clip – 1: 48: 01 – 1: 54: 48 Ø Five minute reflection: Ø What are you hearing from Cory? Ø What are the risk dimensions? Ø What are the treatment targets? Ø What are the cultural issues/challenges?

CASE – CORY Ø Cory Clip – 2: 46: 56 – 2: 49: 09 Ø Second session opening Ø Cory’s Collectivist response Ø Reframing help seeking as collectivist

CASE – KENNEDY 3 – SAFETY PLANNING Ø Collaborative safety (crisis) planning: Ø 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) • It can flow from the “Mood Scaling” assessment technique

SAFETY PLANNING Ø How Can I Make My Environment Safe? Ø My Unique Warning Signs Ø My internal Coping Strategies Ø People and Settings that Provide Support and Distraction Ø Who Can I Ask for Help? Ø Professionals or Agencies I Can Contact for Support Ø How I Can Make My Environment Even Safer?

SAFETY PLANNING Ø I want you to live Ø But I know it’s your choice to live or die Ø Most people feel better after 3 -4 months of counseling Ø Why not give it a try, you can always choose to die later Ø [Mostly adapted from Jobes, 2016; What would Linehan say? ]

ALTERNATIVES TO SUICIDE Ø Show Kay Clip 1: 50: 02 – 1: 54: 34 then 1: 55: 54 – 2: 00: 27 Ø Or JSF Story Ø Alternatives to Suicide is simultaneously assessment and intervention Ø Psychoeducation on Behavioral Activation

CASE 4 – JEANNE -- PASSIVE SI INTERVENTION Ø Active and Passive SI warrant different interventions Ø Jeanne – 66 -y/o with passive SI after death of 2 nd husband Ø Jeanne Clip 1: 21: 32 - 1: 23: 08

TABLE TALK Ø Do the existential 6 months to live intervention with each other Ø Debrief: Thoughts, feelings, impulses. . . ?

IN THE END: DECISION-MAKING Ø No predictive formula; collaborate and use practice standards Ø Consider Distress + Social Factors + Hopelessness + Intent + Problem-Solving + Agitation + Desensitization + Lethal Means Ø Go with a collaborative safety plan if possible Ø Contact parents or guardians, restrict lethal means, intervene on the other seven factors listed above and any idiosyncratic factors as well Ø Always consult

COMMUNITY COLLABORATION ØCollaborative Practice ØFive minute discussion ØWhat are the most effective methods you’ve discovered for engaging in collaborative prevention, intervention, and support in your community? ØSharing

THREE SIMPLIFIED PRINCIPLES 1. How are you taking care of yourself? 2. How are you taking care of others in your family/community? 3. Avoid making rash decisions or using poor judgment

ADVOCACY ØPolitics – Universal ØCommunity – Selective ØHigh Risk Groups – Indicated ØWhat are the effective advocacy strategies in NZ?

CONCLUSION: SUMMARY • Closing Story • Relationship: Collaborate, show empathy, cope with irritability • Assessment: Ask directly, normalize, use mood scaling, use interventions and gauge responsiveness • Interventions: Distress reduction; alternatives to suicide (problem-solving and hopelessness); social universe; safety planning; +

APPENDIX: STRENGTH-BASED RESOURCES • Journal of Health Service Psychology 2018 article • Johnsommersflanagan. com [eight risk dimensions] • Psychotherapy. net video training –

CHECK UP AND CHECK -IN

CONCLUSION: REMINDERS • The mind is a terrible place to go. . . Alone • Which is why we should keep on talking—directly to each other and to our students, clients, and community—about suicide and suicide prevention.