Basic information for working with someone who may be suicidal

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

2. 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

3. 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)

4. 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)

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

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

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

8. 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

9. 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.

10. 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.

11. Prevalence:
How Big is the Problem?

12. Prevalence:
How Big is the Problem?

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

14. 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)

15. Understanding Suicidality

16. 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

17. 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”

18. Intent/Lethality as Related to Risk
High Low
Intent
Lethality

19. Intent/Lethality as Related to Risk
High Low
Intent
Lethality

20. Intent/Lethality as Related to Risk
High Low
Intent
Lethality

21. Intent/Lethality as Related to Risk
High Low
Intent
Lethality

22. Intent/Lethality as Related to Risk
High Low
Intent
Lethality

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

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

32. 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...

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

34. 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

35. 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

36. 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...

37. 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?

38. Practice Implications

39. 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

40. 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

41. 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.

42. 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

43. 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)

44. 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

45. 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

48. 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)

49. 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

50. 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

51. 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

52. 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

53. Safety Issues

54. Safety Issues

55. 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

56. 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.

57. 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?

58. 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?

59. 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

60. 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

61. 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

62. 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

63. 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.

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

65. 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%

66. 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

67. Discharge Planning, the
importance of follow up
connection

68. 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)

69. 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

70. 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

71. 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

72. 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

73. Motto et al, Results

74. Motto et al, Results

75. Motto et al, Results

76. 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.”

77. 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.”

78. 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.”

79. 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.”

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