Important Things To Know

Important things to know in working with suicidal client Michael McFarland, LMFT Division of Behavioral Health

Where we are headed Frame the critical role of MH providers for suicide prevention Gain a glimpse of the prevalence Understand some core features of suicidality ✓ General conceptual considerations ✓ Basic model Consider some practice implications

Did you Know? Every year, over 33,000 people end their lives by suicide Between 30% and 50% of suicides in the United States occur in people who are receiving psychiatric treatment (Luoma, Martin, Pearson (2002); Lambert (2002)

Trends in Suicidal Behavior 1990-1992 vs 2001-2003 National Comorbidity Survey Survey

What happens when we... increase public awareness broaden access to services BUT don’t address TX ✓ Tx modalities and evidenced based protocols (What we do) ✓ Provider “know how” for engaging such clients (How we do it) ✓ Did you know the average clinician receives only about 2 hours of direct education around suicidality

The Challenge The assessment, management, and treatment of suicidality in clinical practice is one of the most challenging and stressful tasks for any clinicians. Helping our clients ﬁnd a way to choose life is the most critical of all clinical endeavors.

Prevalence: How Big is the Problem?

Prevalence: How Big is the Problem? 1 million deaths by suicide worldwide every year

The Reality >33,000 die annually by suicide in the US 11th leading cause of death 2:1 suicide deaths to homicide deaths KY has the 12th highest rate of death by suicide in the nation 3:1 suicide deaths to homicide deaths 2nd leading cause of death in KY for those 15-34 yrs of age 4th leading cause of death in KY for those 35-54 yrs of age 65% of all suicide deaths in KY involve a ﬁrearm (2007)

Understanding Suicidality

Suicidality: General Conceptual Considerations Suicidality is time-limited ‣ suicide risk comes and goes Episodes of risk vary in severity and duration ‣ recovery trajectories vary across individuals, sometimes longer than we might guess Vulnerability for a new episode varies across individuals ‣ Variable conﬁgurations of predisposing risk factors ‣ Variable “thresholds” of activation

Suicidality: General Conceptual Considerations Intent is variable, it comes and goes Variations in intent can occur very quickly for some Intent is inﬂuenced by a complex web of factors Internal and external Ambivalence is almost always present Most motivations for death revolve around “putting an end to suffering”

Intent/Lethality as Related to Risk High Low Intent Lethality

Intent/Lethality as Related to Risk High Low Compounding Complexity Intent Subjective 1. how intently want to die 2. to what extent expects to die Objective 1. how likely from Lethality medical perspective

SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidity Personality Neurobiology Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Suicide Illness Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior

Thomas Joiner: Interpersonal- Psychological Theory Developed Ability Desire to die 1. Increased capability, overcome self- 2.“Perceived” burdensomeness preservation instinct through repeated 3. Failed belonging experience w/pain and provocation-- habituation Convergence Zone resulting in serious suicide attempt, or completion 44

Developed Capability Those who repeatedly attempt suicide emphasize how difficult it is...it is difficult to overcome the most basic instinct of all; namely self-preservation. (Joiner, 2005) 45

Developed Capability Those who repeatedly attempt suicide emphasize how difficult it is...it is difficult to overcome the most basic instinct of all; namely self-preservation. (Joiner, 2005) ‣Accrues with repeated and escalating experiences involving pain and provocation, such as ‣ Past suicidal behavior, but not only that... ‣ Repeated injuries (e.g., childhood physical abuse); IV drug use ‣ Repeated witnessing of pain, violence, or injury (cf. physicians) ‣ Any repeated exposure to pain and provocation 45

1. Perceived Burdensomeness 2. Perceived Fail Belongingness Desire to die

1. Perceived Burdensomeness 2. Perceived Fail Belongingness Hopelessness Desire to die

Perceived Burdensomeness ‣ Burdensomeness has to do w/ a person’s sense of self ‣ Defective; ﬂawed to the point they perceive themselves as a “burden” to others, the world, etc. therefore...

FATAL misperception (cognitive distortions and information processing---cognitive elements that feed the suicidal mindset Hopelessness tied to helplessness ‣ Opposing concept: self-efﬁcacy/effectiveness

Understanding The Suicidal Perspective Can’t stop the pain Can’t think clearly Can’t make decisions Can’t see any way out Can’t sleep, eat or work Can’t get out of the depression Can’t make the sadness go away Can’t see the possibility of change Can’t see themselves as worthwhile Can’t get someone’s attention Can’t see to get control

Failed Belongingness Fundamental human need for connection So strong that if present it can be a preventative even when other two factors are in place. Most usual precipitant for suicide is a broken relationship Motto... Therapeutic implications...

Tells Us What We Should be Exploring!  Willingness to act (motivation to die) – What are your reasons for dying?  Preparation to act (preparation and rehearsal behaviors) – Have you prepared for your death in any way?  Will, letters, finances, research? – Have you rehearsed your suicide?  Capability to act (previous suicidality, self-harm, trauma exposure) – Have you made a previous suicide attempt(s)? – Have you ever done things to harm or hurt yourself? – Have you ever experienced something you consider traumatic?  Barriers to act (reasons for living) – What are your reasons for living? – What keeps you alive, what keeps you going?

Practice Implications

Therapeutic Connection and Collaboration are a Priority Research indicates one of the MOST important factors predicting positive therapeutic outcome is the nature of the therapeutic relationship [carries more weight than model/ techniques]; (Norcross, Beutler & Levant, 2005; Siegel, 2010) Clinician characteristics... ✓ Presence ✓ Attunement Healing Relationship ✓ Resonance See, The Mindful Therapist, Daniel Siegel

Nature and response to suicidal crisis Understand… ALLIANCE Response Suicidal thinking and Validate depth of pain- behaviors makes sense Listen to client Maintain nonjudgmental/ Serves a functional supportive stance purpose Voice authentic concern Psychache View each client individually Keep focus on resolving pain; not simply controlling suicidal behavior.

Make it a habit...ASK Ask EVERY client about past and current suicidality Periodically re-check with clients who have previously denied Sullivan (2004) only 77% of clinical psychologists registered with the APA practice directorate reported performing suicidal ideation inquiries during the initial session with new patient

Eliciting Suicidal Ideation: Use A Hierarchical Approach  Elicit past, present, and current suicidal thoughts, behaviors, plans, intent  Sequence and word questions in effective manner to reduce anxiety, resistance and increase accuracy – First attempt, past several years (worst attempt---if multiple attempter), THEN current episode  Address client fears about “what will happen” if suicidal thoughts are acknowledged  Always thinking about……. – Severity (related to specificity) – Immediacy (Intent) – Volatility (impulsivity/self-control)

ALWAYS BE SPECIFIC  Speciﬁcity of questions improves assessment, reduces distress (use “kill yourself”, “suicide”) –No iatrogenic effect  Gould et al., Linehan et al.  Nature of Suicidal Thinking – Ideation: [FIDS] Frequency, Intensity/severity, Duration, Speciﬁcity (plans), availability/accessibility, active behaviors (preparation, rehearsal), intent (subj. vs. obj.), perceived lethality, degree of ambivalence, deterrents (family, religion, positive treatment relationship, support system) – Severity of psychological distress (Psychache)  Distress tolerance

Ask About Attempt Hx For previous attempts ➡ P =Precipitant ➡ N =Nature of attempt ➡ O =Outcome ➡ R =Response • Distinguish between chronic and acute ‣ Crisis threshold of activation  Multiple suicide attempters-more easily enter suicidal crisis from a broader array of triggers  Greater symptom severity: Anxiety, depression, hopelessness, anger, suicidal ideation (frequency, intensity, speciﬁcity, duration, intent) ‣ Crisis duration  Suicidal crisis for longer duration than SSA

The Most Critical Risk Factors: What’s the Empirical Evidence?  Anxiety/Agitation –Mental status impairment  Sleep Disturbance –Mental status impairment –Nightmares  Perceived Burdensomeness –Lack of social support (the most important protective factor)

What effective treatments have in common Tend to be CBT based Target suicidality directly Provides client with understandable model about suicidality Enhance skill deﬁcit Provide crisis management Monitor treatment compliance Limit access to lethal means

Case Conceptualization • It is vital that clients deconstruct their suicidal cycle— explore it, move into it. • Support clients identifying components; recognizing patterns or themes associated with their cycle • Create a narrative of event • Construct a timeline Wenzel, Brown, Beck (2009). Cognitive Therapy for Suicidal Patients; Rudd, Joiner, & Rajab (2001). Treating Suicidal Behavior: An effective, time-limited approach

Case Conceptualization • It is vital that clients deconstruct their suicidal cycle— explore it, move into it. • Support clients identifying components; recognizing patterns or themes associated with their cycle • Create a narrative of event • Construct a timeline As long as suicidal clients are unable to understand their suicidal cycle, they remain victims to it. Wenzel, Brown, Beck (2009). Cognitive Therapy for Suicidal Patients; Rudd, Joiner, & Rajab (2001). Treating Suicidal Behavior: An effective, time-limited approach

Safety Issues

Safety Issues non- harm plan vs. safety 1. C risis eans ontra ct f leth al m c eme nt o Ma nag 2. plan ning 3 . DC

Regarding “no harm” contracts Not a legal document; cannot be used in the event of litigation Although commonly used, no studies have shown their effectiveness in reducing suicides Suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Therefore, use in ED settings or with newly admitted and unknown inpatients is not recommended.

Regarding “no harm” contracts Not a legal document; cannot be used in the event of litigation Although commonly used, no studies have shown their effectiveness in reducing suicides Suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Therefore, use in ED settings or with newly admitted and unknown inpatients is not recommended. Who said this?

Crisis safety plan  Prioritized written list of coping strategies See and handouts resources for use during a suicidal crisis.  Uses a brief, easy-to-read format that uses the patients’ own words.  Development and implementation of a safety plan IS treatment  Should be the first intervention with a suicidal patient  Helps to immediately enhance client’s sense of control over suicidal urges and thoughts and conveys a feeling that they can “survive” suicidal feelings  Enhances coping skills  Provides concrete steps to guide client during crisis  Enlist’s client’s collaboration

Addressing access to lethal means Access to certain highly lethal means is always one of the most important risk factors to consider Research indicates addressing this issues is often absent in conversations between client and provider Critical risk management issue & treatment issue

Means Matter Poisoning is involved in 74% of attempts, but has a case fatality rate of 2% Guns are involved in 5% of attempts, but have a case fatality rate of 91% When a gun is used in an attempt 85% of the time it results in fatality Firearm factors... ‣ Inherently lethal ‣ Immediacy ‣ Irreversibility ‣ Most other means provide opportunity for “backing out”--even hangings; about half of the hangings deaths are partial suspension

Social Worker Behaviors Respondents: 700 LCSW’s Questions concerning practice within last 2 years... 1. “I routinely assess if my clients own a gun and have access to guns.” 2. “I routinely counsel my clients about ﬁrearm safety.” Slovak, Karen, Briver, Thomas, W., Carlson, Karen. (2009). Client Firearm Assessment and Safety Counseling: The Role of Social Workers. Social Work.

Social Worker Behaviors Slovak, Karen, Briver, Thomas, W., Carlson, Karen. (2009). Client Firearm Assessment and Safety Counseling: The Role of Social Workers. Social Work.

Factors affecting response If endorsed not being adequately trained... ‣ Odds of routine firearm assessment decreased by 67% ‣ Odds of safety counseling occurring decreased by 86% If reported not being aware of risks associated with with firearms in the home... ‣ Odds of routine firearm assessment decreased by 60.3% ‣ Odds of safety counseling occurring decreased by 52.9%

Principles of Lethal Means Safety Management Accessibility to lethal means is a treatment issue Inquire about guns at home or outside the home (car, ofﬁce, etc.); intention to purchase a gun Explain the elevated risk Adopt common MI stance; think about the stages of change Designate a willing, responsible person to remove and safely secure guns & ammunition outside home and unknown to client; secure medications Have direct phone contact w/ designated person for conﬁrmation; DOCUMENT

Discharge Planning, the importance of follow up connection

Post Discharge Heightened Risk  Heightened risk for suicidality has been broadly recognized across  Differing countries  Differing populations  Differing time periods  Estimated 6% of all suicides occur in the immediate post discharge period (Troister et al, 2008)  41% of suicides among those received psychiatric care can occur within 1 year of d/c.  Additional clustering within 1st month/ esp. 1st wk is also evident (Pirkola et al, 2005)

Potential Factors Loss of immediate support system Increased opportunity with access to means Medication compliance Follow up compliance Questionable stability at D/C Lack of change in social stressors— basic life conditions remain unchanged

Take Home Message  Vast majority denied SI at D/C  Nevertheless, the majority (re) experienced SI within the ﬁrst 2 months of d/c to outpt tx.  Pt. d/c with ongoing depressive symptomatology appear to be a increased risk for SI+ as well as subsequent rehospitalization

Connection impact among pt’s refusing follow-up, Motto &  Refusing follow up care is widespread, 11% to 50% reported in numerous studies  1969-1974, total of 3,005 in nine inpat. Psych CT=30 days D/DT ≠ 30 Died w/n 30 of D/C TG NFTG Undetermined Ltr. 1 per month for 4 months (4) 1 every 2 months forNCG CG 8 months (4) 1 every 3 months for 4 yrs (16) total 5 yrs and 23 contacts

Connection impact among pt’s refusing follow-up, Motto &  Refusing follow up care is widespread, 11% to 50% reported in numerous studies “Dear___________:  1969-1974, total oftime since you It has been some 3,005 in nine inpat. Psych a the hospital, and D/C CT=30 days D/DT ≠ 30 were here Died w/n 30 of we hope tings are going well for you. TG NFTG Undetermined If you wish to drop us a note we Ltr. would be glad to here from you.” 1 per month for 4 months (4) 1 every 2 months forNCG CG 8 months (4) 1 every 3 months for 4 yrs (16) total 5 yrs and 23 contacts

Motto et al, Results

Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.” “You are the most persistent son of a bitch I’ve ever encountered, so you must really be sincere in your interest in me.”

Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.”

Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.” “You are the most persistent son of a bitch I’ve ever encountered, so you must really be sincere in your interest in me.”

Contact Information In transition... Michael McFarland michaelw.mcfarland@gmail.com 502.544.7663

Important Things To Know

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